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EXTRAUTERINE 
PREGNANCY 


EXTRAUTERINE 
PREGNANCY 


BY 


EDWARD  A.  SCHUMANN,  M.D. 

lecturer    on    obstetrics,    jefferson    medical    college;    gynecologist    and 
obstetrician  to  the  philadelphia  general  hospital;  gynecologist 
to  frankford  hospital;  consulting  gynecologist  to  rush  hos- 
pital; assistant  obstetrician  jefferson  medical  college 
hospital;  fellow  of  the  American  gynecological 
society,  obstetrical  society  of  philadelphia,  etc. 


GYNECOLOGICAL  AND   OBSTETRICAL   MONOGRAPHS 


WITH  SEVENTY-ONE   ILLUSTRATIONS 


D.  APPLETON  AND  COMPANY 


NEW  YORK 


LONDON 


1921 


101 

&cicil 

mi 


COPYRIGHT,    1 9  21,   BY 

D.  APPLETON  AND   COMPANY 


PRINTED  IN  THE  UNITED  STATES  OF  AMERICA 


PREFACE 

Progress  in  surgery,  both  from  the  scientific  side  and  from  the  purely 
practical  clinical  aspect,  is  perhaps  as  well  summarized  by  a  study  of  the 
advance  in  thought  concerning  extra-uterine  pregnancy  as  may  be  pos- 
sible. 

Less  than  two  generations  ago,  the  woman  to  whom  befell  the 
calamity  of  a  ruptured  tubal  pregnancy,  was  doomed  to  almost  certain 
death,  without  benefit  of  any  rational  attempt  being  made  to  save  her. 

To-day  the  mortality  of  this  formerly  dreaded  accident  has  been  re- 
duced to  below  five  per  cent. 

This  book  has  been  prepared  to  emphasize  the  progress  and  to  present 
modern  thought  concerning  the  several  problems  arising  from  a  con- 
sideration of  various  phases  of  ectopic  gestation. 

Especial  attention  has  been  paid  to  the  etiology  and  pathology  with 
a  view  toward  grouping  and  epitomizing  rational  explanations  as  to 
the  cause  of  the  condition. 

American  views  have  been  particularly  embodied  in  the  work  and  the 
ideas  presented  may  be  said  to  reflect  the  general  trend  of  opinion  upon 
this  subject,  in  this  country  at  this  time. 

Illustrative  case  histories  have  been  incorporated  from  time  to  time 
but  no  attempt  has  been  made  to  reproduce  in  full,  verbose  and  irrele- 
vant anamneses. 

The  original  material  consists  of  cases  occurring  in  the  service  of 
the  writer  at  the  Philadelphia  General,  Jefferson,  Frankford  and 
Gynecean  Hospitals  and  the  management  of  ectopic  gestation  as  out- 
lined is  that  practiced  by  him  in  these  institutions. 

The  author  is  indebted  to  the  publishers,  Messrs,  D.  Appleton  and 
Company,  for  many  acts  of  kindness  ;  to  Mrs.  Gertrude  V.  Schwartz  for 
her  painstaking  and  careful  illustrations,  to  Miss  Marion  E.  Tighe  for 
her  faithful  preparation  of  the  text  and  to  Dr.  Charles  P.  Noble  for  his 
helpful  criticism  and  suggestions. 

Edward  A.  Schumann 

PHILADELPHIA 


CONTENTS 

CHAPTER  PAGE 

I.    Historical  Considerations i 

Development  of  modern  methods  of  treatment,  I — Extra-uterine 
pregnancy  unknown  to  the  ancients,  i— First  recorded  case,  i — Case 
reported  by  Cordseus,  3 — Essay  of  Dr.  Campbell,  4 — Monograph  of 
John  S.  Parry,  4 — Review  of  H.  C.  Kelly,  4 — Case  of  Cornax,  4 — 
Case  of  Jacob  Nufer,  4 — Bain's  operation,  5 — Case  of  Primrose,  6 — 
Case  of  Dr.  Felix  Platerus,  6 — Case  reported  by  Calvo,  6 — Case  of 
Riolanus,  7 — Mauriceau's  case,  7 — 'Work  of  Pierre  Dionis,  9 — First 
recorded  case  in  America,  9 — Second  recorded  case,  10 — Mono- 
graph of  Dezeimeris,  10 — Parry's  Book,  11 — Work  of  Lawson  Tait, 
12 — Use  of  electricity  advocated,  15 — History  of  treatment,  12 — 
Treatment  of  rupture  of  the  cyst,  12 — Treatment  suggested  by  Dr. 
Harbert,  14 — Treatment  suggested  by  Stephen  Rogers,  14 — Case  of 
Dr.  Charles  Briddon,  15 — Experiments  of  Dr.  Hunter  Robb,   15. 

II.    Definition,  Frequency,  Causes 17 

Definition,  17 — Frequency,  17 — Race  incidence,  19 — Age,  19 — The 
varieties  of  extra-uterine  gestation,  19 — The  relative  frequency,  21 — 
The  causes  of  extra-uterine  pregnancy,  22^-Obstruction  of  the  tubal 
lumen  from  without,  23 — Anomalies  of  the  tubal  lumen,  accessory 
tubes,  etc.,  into  which  the  ovum  falls,  25 — Decidual  reaction  of  the 
tube,  26 — The  external  migration  of  the  ovum,  27 — The  cause  of 
ovarian  pregnancy,  31 — The  cause  of  primary  abdominal  pregnancy, 
31. 

III.  The   Terminations   of   Ectopic   Pregnancy 33 

Termination  by  resorption  of  the  ovum,  34 — Death  of  the  embryo  with 
the  formation  of  tubal  mole,  34 — Tubal  abortion,  34 — Rupture  of 
the  pregnant  tube,  37 — Rupture  between  the  folds  of  the  broad  liga- 
ment, 39 — The  growth  and  development  of  the  fetus  to  full  term, 
while  still  confined  within  the  tube,  41 — Interstitial  pregnancy  may 
terminate  by  the  gradual  growth  of  the  fetus  into  the  uterine  cavity, 
41 — Tubo-abdominal  pregnancy,  42 — Secondary  abdominal  pregnancy, 
42 — Tubo-ovarian  pregnancy,  43 — Intraligamentary  pregnancy,  43— 
Ovario-abdominal  pregnancy,  44 — Abdominal  pregnancy,  secondary 
to  primary  ovarian  pregnancy,  44 — Resorption  and  tubal  mole,  44 — 
Hematocele,  44 — Solitary  hematocele,  45 — Infected  hematocele,  45 — 
The  terminal  changes,  46. 

IV.  The  Anatomy  and  Pathology  of  Extra-Uterine  Pregnancy   ...      47 

The  mode  of  implantation  of  the  ovum  in  the  tube,  47 — Placentation 
in  tubal  pregnancy,  55 — Changes  in  the  uterus  produced  by  ectopic 
pregnancy,  62 — The  relation  of  uterine  decidua  and  decidual  casts 
to  ectopic  pregnancy,  63 — The  cast  of  membranous  dysmenorrhea,  67 
— The  pathology  of  interstitial  or  cornual  pregnancy,  69 — The  path- 
ology of  ovarian  pregnancy,  73 — Placentation,  75— The  pathology  of 
pelvic  hematocele,  77— The  pathology  of  advanced  ectopic  pregnancy, 
79— Changes  in  the  tissues  the  result  of  ectopic  pregnancy,  84 — 
Diagnosis  of  ectopic  pregnancy,  85— The  fate  of  the  embryo  in 
ectopic  pregnancy,  87. 

V.    Recurrent    Extra-Uterine    Pregnancy 101 

Twin  ectopic  pregnancy,  104 — Combined  intra-  and  extra-uterine 
pregnancy,     108— Complicated    extra-uterine    pregnancy,     109— Tubal 


viii  CONTENTS 

CHAPTER 


PAGE 


pregnancy  and  fibroid  tumors  of  the  uterus,  109— Unique  forms 
of  ectopic  pregnancy,  in — Hemorrhage  from  ovary  or  tube  simulat- 
ing ruptured  ectopic  pregnancy,  113. 

VI.  The  Diagnosis  and  Symptomatology  of  Extra-Uterine  Pregnancy  .  118 
The  previous  history,  127— Absolute  sterility,  127— Preexisting  pelvic 
disease,  129— The  general  health  and  the  medical  history  of  the 
patient,  130 — The  findings  on  general  examination  of  the  patient, 
131— Blood  pressure,  134— The  diagnosis  of  ectopic  pregnancy,  136— 
Diagnosis  of  long  existing  and  untreated  ectopic  gestation,  141 — Diag- 
nosis of  ectopic  pregnancy,  other  than  tubal,  143— Ovarian  pregnancy, 
I45 — Abdominal  pregnancy,  146 — The  diagnosis  of  lithopedion  or 
adipocere,  147 — The  diagnosis  of  complicated  ectopic  gestation,  147 
—The  differential  diagnosis  of  ectopic  pregnancy,  148— Differentiation 
of  ectopic  gestation  from  acute  salpingitis,  151 — The  histological  diag- 
nosis of  extra-uterine  pregnancy,  157. 

VII.    Treatment l6: 

Treatment  before  rupture  has  occurred,  161— The  treatment  of  the 
affected  tube,  166— The  treatment  of  the  remaining  tube,  167— The 
management  of  abdominal  lesions,  not  connected  with  the  ectopic 
pregnancy,  168— The  closure  of  the  incision,  168— The  treatment  of 
advanced  extra-uterine  pregnancy,  173— The  treatment  of  advanced 
ectopic  pregnancy  when  the  fetus  is  known  to  be  dead,  176 — The 
treatment  of  infected  and  suppurative  ectopic  pregnancy,  176— The 
treatment  of  hematocele,    176— Mortality  and  prognosis,   177. 

Index l79 


ILLUSTRATIONS 


9- 
10. 
ii. 

12. 

13- 

14. 

IS- 

16. 

17- 
18. 
19. 

20. 

21. 
22. 
23- 

24. 

25- 

26. 
27. 
28. 
29. 
30. 

31. 

32. 

33- 


Text  of  Albucasis'  case 

The  lithopedion  of  Sens 

Mauriceau's    case 

Pierre  Dionis'  case   . 

Sites  of  ectopic  gestation 

Polypoid  chondrofibroma  of  the  fallopian  tube,  associated  with  tubal 
pregnancy 

Chondrofibroma  of  fallopian  tube 

Chondrofibroma  of  fallopian  tube 

Ruptured   tubal   pregnancy 

A  tubal  mole     .... 

A  tubal  mole,  the  fetus  still  intact,  but  undergoing  degeneration 

Section  of  a  tube  showing  incomplete  tubal  abortion 

A  tube  removed  a  few  hours  after  complete  tubal  abortion  had  taken 
place 

Rupture  of  a  pregnant  tube  subsequently  to  the  development  of  tubal 
abortion      ........ 

Section  through  uterine  portion  of  tube 

Section  through  isthmic  portion  of  tube     . 

Section  through  ampullar  portion  of  tube  . 

Tubal  pregnancy  caused  by  diverticula  of  fallopian  tube 

Cross  section  of  fallopian  tube  of  the  coati 

Section  of  fallopian  tube  of  duvanceli,  showing  the  straight  and  simpl 
Rugae         ........ 

Trophoblast  cells  between  muscle  bundles  of  tube  walls 

Rupture  of  a  gestation  sac  within  the  tube  lumen 

Beginning  rupture  of  an  isthmial  pregnancy  on  the  inner  posterior 
aspect  of  the  tube 

Late  rupturing  tubal  pregnancy 

A  gestation  sac  with  large  surrounding  blood  clot  found  lying  free  in 
the   peritoneal   cavity  ..... 

Uterine  changes  consequent  on  ectopic  pregnancy  (I) 

Uterine  changes  consequent  on  ectopic  pregnancy  (II) 

Uterine  changes  consequent  on  ectopic  pregnancy  (III) 

Decidua  of  uterus  in  case  of  tubal  pregnancy    . 

Microscopic  section  of  decidual  cast 

Decidua  cells    ........ 

Schematic  representation  of  an  interstitial  pregnancy  of  four  months 

A  mole  pregnancy  in  the  right  uterine  cornu     ..... 


3 

8 

9 
20 

27 
28 
29 
30 
35 
35 
36 

36 

38 
48 
48 

49 
50 
51 

52 
56 
57 

58 
60 

61 
64 
64 

65 
66 
68 
69 

7i 

72 


ILLUSTRATIONS 


FIGURE 

34.  An  interstitial  pregnancy  which  had  ruptured,  literally  blowing  the 

anterior  uterine  wall  into  fragments    . 

35.  Ovarian  pregnancy:  Posterior  view   (I)    . 

36.  Ovarian  pregnancy :  Macroscopic  section    (II)   . 

37.  Ovarian  pregnancy:  Microscopic  section  (III)   . 

38.  Ovarian  pregnancy :  Microscopic  section  (IV)   . 

39.  Ovarian  pregnancy:  Microscopic  section    (V)    . 

40.  Ovarian  pregnancy:  Microscopic  section  (VI)   . 

41.  Pelvic  hematocele   following  tubal   abortion 

42.  Blood  mass  surrounding  ruptured  tube 

43.  Microscopic  section  of  primary  chorio-epithelioma  of  tube 

44.  Decidual  tissue  in  the  appendix        .  . 

45.  Decidual   tissue   in   a    parovarian   cyst 

46.  Fetal  bones  taken  from  abdomen  after  rupture  of  pregnant  uterus 

47.  Lithokelyphopedion    ....... 

48.  Lithopedion   from  sac  shown  in  Fig.  47. 

49.  True  lithopedion       ....... 

50.  Lithopedion  lying  undisturbed  in  the  abdominal  cavity 

51.  Lithopedion  removed  from  the  abdominal  cavity  four  years  after 

false  labor  .  •    . 

52.  Twin  ectopic  pregnancy     ..... 

53.  Triplet  ectopic  pregnancy  .... 

54.  Cervical   pregnancy  with   rupture   into  abdomen 

55.  Cervical    pregnancy  ..... 

56.  A  hematoma  of  the  tube    ..... 

57.  Uterus  crowded  down  below  gestation  sac 

58.  Uterus  pushed  down  by  gestation  sac 

59.  Section  through  attachment  of  villi  to  tube  wall 

60.  Section  through  veins  in  tube  wall     . 

61.  Section  through  vacuolated   syncytium 

62.  Syncytium  covering  a  typical  villus  . 

63.  Villus  undergoing  fibrous  degeneration 

64.  Section  through  ovum  adjoining  tube  wall 

65.  Tip  of  a  fibrous  villus      ..... 

66.  Section  through  a  necrotic  villus 

67.  Section  of  vacuolated  syncytium   filled  with  leukocytes 

68.  Extreme  degeneration  of  the  syncytium   . 

69.  Group  of  villus  cells  growing  into  mesenchym   . 

70.  Blood  supply  of  fallopian  tube    .... 

71.  The  details  of  salpingectomy  for  the  removal  of  a  tubal  pregnancy 


EXTRA-UTERINE   PREGNANCY 


CHAPTER  I 

HISTORICAL  CONSIDERATIONS 

Development  of  Modern  Methods  of  Treatment — Extra-uterine  Pregnancy  Unknown 
to  the  Ancients — First  Recorded  Case — Case  Reported  by  Cordaeus — Essay  of 
Dr.  Campbell — Monograph  of  John  S.  Parry — Review  of  H.  C.  Kelly — Case  of 
Cornax — Case  of  Jacob  Nufer — Bain's  Operation — Case  of  Primerose — Case  of 
Dr.  Felix  Platerus — Case  Reported  by  Calvo — Case  of  Riolan — Mauriceau's  Case — 
Work  of  Pierre  Dionis— First  Recorded  Case  in  America — Second  Recorded 
Case — Monograph  of  Dezeimeris — Parry's  Book — Work  of  Lawson  Tait — Use 
of  Electricity  Advocated — History  of  Treatment — Treatment  of  Rupture  of  the 
Cyst — Treatment  Suggested  by  Dr.  Harbert — Treatment  Suggested  by  Dr.  Stephen 
Rogers — Case  of  Dr.  Chas.  Briddon — Experiments  of  Dr.  Hunter  Robb — Bib- 
liography. 

The  history  of  the  recognition  of  pregnancy  proceeding  outside  the 
cavity  of  the  uterus,  the  gradual  understanding  of  its  gravity  and  the 
development  of  modern  methods  of  its  treatment,  forms  one  of  the  most 
fascinating  episodes  in  that  epitome  of  human  intellect,  its  brilliancies 
and  its  lamentable  failures,  the  history  of  medicine. 

Extra-uterine  pregnancy  was  apparently  unknown  to  the  ancients, 
there  being  no  allusion  to  the  subject  in  the  works  on  Greek  or  Roman 
medicine.  The  first  recorded  case  is  that  of  one  Albucasis,  an  Arabian 
physician  living  in  Spain  and  flourishing  about  the  middle  of  the  eleventh 
century.  He  reports  a  case  wherein  he  saw  parts  of  a  fetal  body  escaping 
from  the  abdomen  of  a  woman  by  the  process  of  suppuration.  An  ab- 
stract of  this  case  report  is  found  in  the  very  complete  text  book  of 
gynecology  and  obstetrics,  "Gynaecorum  sive  de  Mulierum  Affectibus 
Commentarii,"  edited  by  Caspar  Bauhin  and  published  in  Basel  in  1586. 
This  work  is  a  collection  of  essays  by  different  authors;  and  in  the  lec- 
ture by  Francisco  Rousetti  is  found  the  reference  to  Albucasis'  case,  as 
shown  by  the  reproduction  of  the  text  found  on  the  next  page. 

The  following  accurate  translation  of  this  account  of  Rousetti  was 
kindly  furnished  the  writer  by  Professor  W.  B.  McDaniel  of  the  Uni- 
versity of  Pennsylvania : 

"Fourth  Account  of  the  Same  Subject. — If  certain  more  fastidious  readers, 
who  are  pleased  only  with  what  is  ancient,  should  not  be  satisfied  with  these 

1 


2  EXTRA-UTERINE  PREGNANCY 

recent  authors  and  cannot  really  be  convinced  of  anything  except  with  the  utmost 
difficulty,  still  the  authority  of  the  learned  and  highly  distinguished  Arab  surgeon 
and  doctor  Albucasis  will,  I  hope,  prove  satisfactory.  In  the  second  book  of  his 
Treatise  on  Surgery  he  writes  after  this  fashion.  I  have  seen  a  woman  who 
although  a  fetus  in  her  womb  had  died,  yet  became  pregnant  again  and  had  this 
second  child  also  die  in  her.  A  long  time  afterwards  a  swelling  arose  at  the  navel 
itself.  When  this  had  been  opened,  matter  flowed  from  it.  I  was  called  in  to  see 
the  case,  and  although  I  treated  her  for  a  long  time,  the  wound  could  not  be 
healed.  (Presumably  he  means  T  could  not  get  the  wound  to  close  so  that  all 
was  whole  and  firm  again  in  the  part  affected').  And  so  I  applied  strong  medica- 
ments of  the  utmost  drawing  power,  with  the  result  that  a  great  many  bones  came 


H  I  S  T  0  %l  d     IV.    E  I  V  S- 
dent  fubitfti. 

SI  dclicatioribus quibufda Leclon'hus,quibus amiquitas  fo!um  pit. 
cet, neoteric!  hi  citatiatKoresnon  fatisfaciant.nec  alms  iptls  quid- 
qaamnififummacura  difikultateperfuaderipoteft ;  fatisfaciet  tame# 
vt  fpero,doc1i  &  iamprickm  perceiebris  Medici  8c  Chirurgi  Arabis  At- 
bucafisau&ori|as,quilibrofecundofu;E  Chirurgi«,/n  hunc  modura 
fcriWt:  MuiieredS  vidi.in  cuius  vteroinfans  ciWefFer  mortuys,rurfu$ 
tamen  grauida  reddita.qui  etiam  foetus  in  ca  mortuus  Longo  tempore 
p6ft,tumor  in  ipfo  vmbtiico  obortus,quo  apcrto  materia  ctdux.iv.ad  $ 
vocatus  fui » 8c  longo  tempore  traclaui,  nee  tamen  confotidari  potuit; 
quafe.fortifsknaattrahendivipoiiemia  medicament*  applicaus>(kqi 
plurimaolTafuccefsiui  j>dierc,  quo  vifoperterritusfut.cuminAbdo- 
mine  nulla  e0e  offa  fcirem.Qaare omnibus  perpenfis  &  indagatis,  effe 
oflafcetusemortuicognoui.ttavtcumpluraiam  extraxiiTem  eampri* 
ftinsfankati  reftituerim,  eo  folum  excepto ,  quod  Temper  aliquid  per 
ylcus  exfudariLHacienus  Aibucafis  Quod  fi  adhuc  alt  qui  adeo  diraci- 
les  ilnt,quibus  ne  hac  quide  ratione  fatisfiat,vt  qui  omnia  q  ab  Arabib. 
fantprofecla.tanqua Barbara deteftetux.eos ad  Alcxaodru  Benedict* 
^(irailehiftoria  in  fuapraxi,traclatudcdjffkuk. partus  habet,  relego. 


i 


Fig.  i. — Text  of  Albucasis'  Case,  from  Caspar  Bauhin,  1586. 

out  one  after  another,  the  sight  of  which  greatly  frightened  me,  since  I  knew  that 
there  were  no  bones  in  the  abdomen.  Accordingly,  after  having  carefully  weighed 
all  the  facts  and  made  a  thorough  investigation,  I  recognized  that  they  were  the 
bones  of  the  dead  fetus,  and  so  when  I  had  now  extracted  more  of  them,  I  re- 
stored her  to  her  former  health,  excepting  only  that  she  was  always  discharging 
something  through  the  ulcer.  Up  to  this  point  we  have  the  account  of  Albucasis. 
But  if  there  are  still  some  persons  who  are  so  difficult  to  satisfy  that  they  cannot 
even  in  this  way  be  persuaded,  because  they  abominate  everything  that  comes 
from  the  Arabs  as  so  much  barbarian  ignorance,  I  refer  them  to  Alexander 
Benedictus,  who,  in  his  treatise  on  the  difficulties  of  childbirth,  has  a  similar 
story  from  his  own  practice." 

This  case  of  Albucasis  was,  of  course,  one  of  old,  long  retained  sec- 
ondary abdominal  pregnancy,  and  indeed,  all  of  the  older  cases  were  of 
this  variety. 


HISTORICAL  CONSIDERATIONS  3 

Another  interesting  example  is  that  of  the  lithopedion  of  Sens  re- 
ported by  Cordaeus  early  in  the  sixteenth  century.  A  cut  of  this  litho- 
pedion with  its  description  is  published  by  Rousetti  in  Bauhin's 
Gynecorum  (q.v.)- 

Speaking  of  this  lithopedion,  Rousetti  says  "We  must  subjoin  to  this 
treatise  the  monstrosity  called  the  Lithopedion  or  petrified  embryo  from  the  city 
of  Sens.    Although  indeed  that  may  be  had  in  its  entirety  in  the  commentaries  of 


<n 


:&:rWk    % 


WrT^ 


.\ 


•i  <■ 





iSS  W-n- 


'■:!'  '.iljj/.i'.k 


Fig.  2. — The  Lithopedion  of  Sens.     From  Bauhin's   Commentarii,  1586. 


Cordaeus,  we  have  inserted  in  this  place  a  picture  of  it  that  was  left  out  in  Cor- 
daeus, that  we  may  not  without  reason  fail  to  satisfy  any  desire  of  yours." 

This  case  led  to  the  publication  of  an  interesting  epigram,  by  an  un- 
known author,  the  translation  of  which  has  also  been  kindly  given  by 
Prof.  McDaniel: 

"Deucalion,  hurling  stones  behind  his  back,  fashioned  from  the  hard  marble 
our  soft  race :  how  does  it  happen  that  now,  by  a  change  of  lot,  the  tender  little 
body  of  a  baby  has  limbs  that  are  most  like  stone?  Divine  power  used  to  bend 
the  manners  of  the  men  of  old,  but  nowadays  our  untamed  necks  bear  no  yoke." 


4  EXTRA-UTERINE  PREGNANCY 

Following  these  cases,  others  are  recorded  with  increasing  frequency. 
In  compiling  the  history  of  the  scattered,  early  records,  the  writer  is 
greatly  indebted  to  two  works,  one,  a  most  scholarly  and  readable  essay, 
entitled  "A  Memoir  of  Extra-uterine  Gestation,"  by  Wm.  Campbell  of 
Edinburgh  and  published  in  1842;  the  other,  the  classic  monograph  of 
John  S.  Parry  of  Philadelphia,  "Extra-uterine  Pregnancy,"  Phila., 
1876,  one  of  the  epoch  making  works  on  this  subject.  The  excellent 
historical  review  by  H.  C.  Kelly  in  a  discussion  before  the  Baltimore 
Gynecological  Society  in  1890,  and  the  article  of  Bovee,1  have  also  been 
of  great  service.  Free  use  has  been  made  of  these  excellent  references 
in  outlining  the  sequence  of  medical  thought  upon  the  matter  of  ectopic 
pregnancy. 

After  the  lithopedion  of  Sens,  there  occurred  a  case  in  the  early  half 
of  the  sixteenth  century,  that  of  Cornax.2  "In  the  early  half  of  the 
sixteenth  century  Cornax  dilated  an  ulcer  which  formed  near  the  umbili- 
cus, and  extracted  a  semiputrid  fetus,  which  had  been  retained  for  nearly 
five  years.  When  the  patient  arrived  at  the  termination  of  her  preg- 
nancy, pains  resembling  those  of  labor  supervened,  and  were  followed  by 
an  unusual  sound  in  the  abdomen,  but  the  uneasiness  did  not  subside. 
For  four  years  the  abdomen  continued  distended  and  painful;  and  at 
last,  a  fetid  discharge  issued  per  vaginam.  First  one  abscess,  and  there- 
after another,  formed  at  the  umbilicus :  these  were  dilated  by  an  incision 
eight  inches  in  length,  and  the  fetus  removed.  The  woman  recovered 
so  well  after  the  operation  as  to  conceive  again,  and  she  had  a  natural 
delivery,  but  died  some  time  thereafter.  This  case  was  considered  by  its 
narrator  as  one  of  rupture  of  the  uterus ;  but  as  the  pains  continued  after 
the  unusual  sound  in  the  abdomen  was  heard,  and  that  there  is  no 
mention  made  of  there  having  been  any  hemorrhage,  it  should  rather 
be  viewed  as  an  instance  of  extra-uterine  gestation." 

In  1500  there  is  found  the  remarkable  case  of  Jacob  Nufer,  which, 
however,  is  usually  considered  as  the  classical  first  case  of  cesarean 
section  on  the  living  woman,  as  no  mention  is  made  as  to  whether  the 
fetus  was  intra-  or  extra-uterine.  The  details  of  Nufer's  case,  as  re- 
corded in  Von  Siebold's  History  of  Obstetrics  (Bovee),  is  as  follows: 
"According  to  the  relation  of  Caspar  Bauhin,  in  his  appendix  to  the 
Latin  translation  of  Fr.  Rousset's  writings  upon  cesarean  section,  Jacob 
Nufer,  a  swine  spayer,  at  Sigerhausen,  in  Switzerland,  in  the  year  1 500, 
delivered  his  own  wife  by  opening  the  abdomen,  and  the  operation  proved 
successful  for  both  mother  and  child.  The  woman  was  pregnant  for  the 
first  time,  and  when  labor  came  on,  and  she  had  already  suffered  se- 
verely for  several  days,  there  had  gradually  assembled  at  her  bedside 


HISTORICAL  CONSIDERATIONS  5 

thirteen  midwives  and  several  lithotomists.  But  all  of  them  together 
were  unable  to  relieve  the  poor  woman  of  her  child  or  to  mitigate  her 
suffering.  Thereupon,  the  husband  of  the  woman  proposed  to  resort 
to  the  last  means  of  saving  her,  and  assured  her  that,  if  she  would  take 
his  advice,  he  hoped,  by  the  blessing  of  God,  to  bring  the  case  to  a  suc- 
cessful issue.  She  gave  her  full  consent,  and  Nufer  persisted  further  in 
having  the  permission  of  the  magistrate  to  his  attempt.  This,  after  some 
reluctance,  was  eventually  obtained.  Nufer  next  asked  those  of  the  mid- 
wives  who  had  sufficient  nerve  for  it  to  assist  him  in  the  delivery  of  his 
wife,  while  the  more  timid  ones  were  requested  to  leave  the  room.  Eleven 
of  them  chose  the  latter  course,  while  two  of  them  and  all  of  the  litho- 
tomists remained  to  assist.  The  husband  first  besought  the  help  of  the 
Almighty,  then  closed  the  door,  laid  his  wife  upon  a  table  and  made  an 
incision  in  her  abdomen  in  the  same  way  he  was  accustomed  with  the 
swine.  He  opened  the  abdomen  so  cleverly  at  the  first  incision  that  the 
child  was  safely  extracted.  When  the  eleven  midwives  outside  the  door 
heard  the  baby  cry  they  desired  admission,  but  this  was  refused  until 
the  baby  was  washed  and  the  wound  closed  as  in  the  swine.  It  healed 
rapidly.  She  was  later  confined  four  times  and  bore  twins.  The  child 
delivered  by  the  operation  lived  seventy-seven  years." 

Forty  years  later  Bain's  operation  was  performed  for  a  long  re- 
tained fetus.  "In  April,  1540,  at  Castrum  Pomponii,  commonly  called 
Pomponischi,  in  the  Province  of  the  Lords  of  Gonzago,  not  far  from  the 
river  Po,  there  lived  a  woman  whose  name  was  Lodovia;  but  from  her 
great  size  termed  LaCavalla.  She  had  been  pregnant  and  the  fetus  had 
died  in  the  uterus,  while  the  soft  parts  had  sloughed  through  the  vulva 
and  the  bony  portions  had  been  retained  within  her.  She  recovered 
and  again  became  pregnant,  followed  by  a  rapid  loss  of  flesh,  and  was 
reduced  to  a  condition  of  great  danger.  Christopher  Bain,  a  traveling 
surgeon,  happened  by  and  offered  to  attempt  to  restore  her  for  ten  golden 
pieces,  if  successful,  and  her  body  if  she  died.  She  and  her  relatives  were 
very  poor,  and  most  of  the  money  was  raised  by  their  good  neighbors. 
The  woman  was  tied  up;  he  slowly  cut  through  the  abdominal  wall,  in- 
cluding the  peritoneum,  and  at  last  opened  the  uterus  and  extracted  the 
skeleton  of  a  male  child;  he  washed  out  the  uterus  with  some  warm  wine 
and  aromatics,  and  after  cauterizing  the  edges  of  the  wound,  closed  it 
with  a  suture.  She  recovered  and  in  a  short  time  had  other  children 
born  in  good  condition.  Later  she  had  four  in  all.  Witnesses :  Dominus 
John  Baptist  Zorzonus,  and  Alexander  Begher,  Dominus  Frederick  de 
Filini,  and  Dominus  Leonellus  Zorzonus,  and  Antonius  Maiochus  or 
Mazzuchinus,  and  several  others,  present  at  the  whole  operation." 


6  EXTRA-UTERINE  PREGNANCY 

Bovee  thinks  this  operation  was  probably  done  to  relieve  an  ectopic, 
but  as  the  description  clearly  states  that  "he  opened  the  uterus  and 
extracted  the  skeleton  of  a  male  child;  he  washed  out  the  uterus  with 
warm  wine,"  etc.,  it  would  appear  that  the  procedure  was  in  reality  a 
hysterotomy,  and  that  the  child  must  have  been  contained  within  the 
uterus. 

The  earliest  absolutely  definite  case  of  surgical  interference  for  the 
removal  of  the  abdominal  fetus,  is  that  of  Primerose  3  in  1594.  "The 
history  of  this  patient  has  become  classical.  She  was  twice  pregnant 
with  extra-uterine  children — first  in  1591,  and  again  some  time  before 
1594.  The  cyst  of  the  first  child  opened  spontaneously  through  the 
abdominal  wall.  The  fistula  was  enlarged,  and  this  child  extracted  by 
Jacob  Noierus,  a  surgeon.  This  operation  proving  successful  Primerose 
removed  the  second  infant  by  gastrotomy  two  months  later.  It  is  easy 
to  imagine  how  he  was  led  to  perform  the  second  and  more  hazardous 
operation." 

"A  case  that  may,  upon  the  whole,  be  considered  very  characteristic, 
is  related  by  Felix  Platerus,  1594,  in  which  the  concubine  of  one  of  the 
sacerdotal  order,  at  the  close  of  her  third  pregnancy,  endured  for  eight 
days  pains  resembling  those  of  labor,  which  then  subsided  without, 
however,  being  followed  by  delivery.  After  having  for  some  time  suffered 
from  a  variety  of  complaints,  a  small  swelling,  the  size  of  an  acorn, 
formed  a  little  above  the  umbilicus ;  it  was  laid  open,  and  an  entire  but 
semiputrid  fetus  extracted  from  the  abdomen;  and  the  hand  thereafter 
introduced  into  the  cavity  for  the  removal  of  any  remaining  portions 
of  the  decomposed  mass.  The  patient  was  restored  to  health,  and  sur- 
vived the  operation  a  year." 

Following  the  case  just  related,  there  is  no  record  of  any  operations 
having  been  performed  for  this  condition  for  more  than  a  century. 
Calvo  4  reported  a  case  in  France  in  1714.  It  will  be  noticed  that  all 
of  the  cases  cited  were  examples  of  full  term  or  long  retained  secondary 
abdominal  pregnancies.  The  first  record  of  tubal  gestation  with  rupture 
and  the  classical  symptoms  of  this  accident  is  that  of  Riolan,  reported  in 
1604.  He  relates  the  case  of  a  lady  aged  thirty-one,  who,  with  the 
exception  of  a  hard,  slightly  painful  tumor  the  size  of  an  egg  or 
clenched  hand,  situated  above  the  right  groin,  experienced  no  unusual  com- 
plaint until  she  was  about  four  months  pregnant  of  her  eighth  child. 
January  2,  1604,  she  was  seized  with  violent  pain  about  the  pubes,  ex- 
tending from  the  pelvis  to  the  upper  part  of  the  chest,  with  occasional 
syncope,  which  continued  till  five  next  morning,  when  she  died.  The 
right  fallopian  tube  was  found  to  have  contained  a  fetus ;  but  the  uterus 


HISTORICAL  CONSIDERATIONS  7 

was  healthy  and  uninjured.  The  same  writer  relates  a  second  example 
of  this  kind  which  occurred  in  1638,  when  the  patient  was  three  months 
pregnant.  She  had  such  distressing  pains  for  four  months  that  she  died 
in  violent  convulsions  in  the  seventh  month  of  pregnancy.  On  dividing 
the  abdominal  parietes,  the  left  fallopian  tube,  much  distended,  and  con- 
taining a  fetus,  presented  itself. 

In  1669  that  master  of  obstetrics,  Mauriceau,  reported  a  case  of 
ruptured  extra-uterine  pregnancy,  the  text  of  his  description  being  as 
follows :  "History  of  a  woman  in  whose  abdomen  there  was  found, 
after  death,  a  small  fetus  about  two  and  one  half  inches  long,  together 
with  a  great  quantity  of  coagulated  blood.  The  history  of  this  case 
deserves  to  be  carefully  examined  into,  to  decide  whether  the  fetus  (as 
believed  by  many)  was  generated  in  the  ejaculatory  vessel,  called  the 
tube  of  the  womb.  On  the  6th  of  January,  1669,  in  the  village  Corrari, 
I  saw  in  the  hands  of  a  chirurgus  called  Benedict  Vassal,  a  uterus,  the 
picture  of  which  is  shown  at  the  end  of  this  chapter,  which  the  same 
chirurgus  had  a  short  time  before  removed  from  the  body  of  a  woman 
aged  32,  who  died  after  three  whole  days  of  torture  with  the  most 
agonizing  pains  in  the  stomach,  through  which  she  had  fallen  into  fre- 
quent fainting  spells  and  the  most  violent  convulsions.  This  woman 
had  borne  eleven  children  at  term,  but  in  her  twelfth  pregnancy,  at  about 
two  and  one  half  months,  the  womb  dilated  in  the  direction  of  the  right 
horn,  and,  unable  to  stand  distention,  ruptured.  The  fetus  was  cast  out 
at  once  and  found  among  the  intestines  of  the  mother,  with  a  great 
quantity  of  coagulated  blood  in  the  whole  lower  abdomen.  Many 
physicians,  chirurgi  and  other  students  of  nature  did  as  did  we  ourselves, 
betook  themselves  to  this  chirurgus  to  see  this  uterus  (which  he  showed 
for  a  prodigy,  persuading  them  that  it  was  formed  in  the  ejaculatory 
vessel,  which  Fallopius  calls  the  trumpet  of  the  womb).  They  believed 
at  once,  without  any  more  investigation,  that  this  was  just  as  the  said 
chirurgus  told  them,  and  that  this  case  confirmed  stories  of  a  like  nature 
narrated  by  Riolanus.  However,  I  examined  the  parts  of  that  uterus 
most  carefully  and  attentively,  and  it  was  known  to  me  that  those  who 
had  fallen  into  this  opinion  were  in  the  error  whither  the  chirurgus  was 
leading  them,  and  for  this  reason,  at  that  very  time,  I  took  a  drawing  of 
the  womb  as  it  then  was,  and  this  is  the  more  faithful,  true  drawing  than 
that  which  the  chirurgus  caused  to  be  engraved  on  brass  after  an  entire 
month,  at  a  time  when  the  uterus  retained  almost  nothing  of  its  primitive 
form,  and  was  spoiled  by  the  handling  of  a  thousand  men  or  more  who 
had  seen  the  uterus,  pulled  it,  disturbed  it,  turned  it  inside  out  that  they 
might  examine  it.    Many  have  brought  forward  this  case  to  prove  to  us 


8  EXTRA-UTERINE  PREGNANCY 

that  the  testes  (ovaries)  of  women  are  full  of  little  ova  which,  at  the 
moment  of  coitus,  freeing  themselves  and  emerging  from  the  body 
proper  of  the  testes  (ovaries),  are  borne  into  the  uterus  through  the 
tube,  afterwards  to  serve  for  the  generation  of  the  fetus;  and  one  of 
these  so-called  ova  had  by  chance  remained  in  the  tube  of  this  woman, 
instead  of  passing  forward  into  the  uterus,  and  that  this  was  the  cause 
of  her  death.  Regnus  Graaf  among  others  holds  this  opinion,  for  the 
confirmation  of  which  he  brings  forward  the  figure  of  this  uterus,  which 
he  painted  from  this  case  which  the  chirurgus  of  whom  I  have  spoken  had 
already  given  to  the  public ;  as  one  finds  it  on  the  260th  page  of  this  book 


Fig.  3. — Mauriceau's  Case  of  Ectopic   Pregnancy    (from   Traite  des  maladies   des 
femmes,  Grones,  Paris,   1675). 

on  the  generative  organs  of  women;  but  any  who  will,  carefully  and 
without  prejudice,  examine  the  following  figure,  which  is  most  faithful 
and  faultless,  and  at  the  same  time  examine  into  our  reasons,  will  find 
that  we  have  given  another  demonstration  and  that  we  believe  that  to  be 
the  true  explanation." 

By  studying  the  illustration,  Fig.  3,  it  is  easy  to  see  why  this  case 
gave  rise  to  the  bitter  controversy  that  followed  its  publication.  It  was 
Mauriceau's  contention  that  generation  in  man  was  accomplished  by  the 
union  of  two  liquid  elements,  the  male  and  the  female,  and  that  accord- 
ingly these  liquids  only  meet  and  cause  fetal  development  in  a  large 
and  suitable  cavity,  as  that  of  the  uterus.  He  held  that  tubal  or  ovarian 
gestation  was  impossible,  and  hence  proved  to  his  satisfaction  that  the 


HISTORICAL  CONSIDERATIONS  9 

case  referred  to  was  a  pregnancy  in  the  uterine  horn.  Study  of  the 
plate  merely  enhances  the  confusion,  since,  while  the  rupture  seems  to 
have  taken  place  in  the  ampulla  of  the  tube,  the  location  of  the  right 
broad  ligament  makes  it  evident  that  the  gestation  sac  must  be  an  elon- 
gated uterine  cornua.  The  question,  therefore,  must  perforce  remain 
unsettled. 

The  first  evidence  of  a  true  understanding  of  the  cause  and  the 
phenomena  of  extra-uterine  pregnancy  is  found  in  the  works  of  Pierre 
Dionis,  5'  6  published  in  1718.  Concerning  the  cause  of  tubal  pregnancy 
Dionis  says  "If  the  egg  be  too  big,  or  if  the  diameter  of  the  tuba  fallopi- 


Fig.  4. — The  Case  of  Pierrre  Dionis.  The  First  Case  of  True  Tubal  Pregnancy 
Ever  Published  (from  the  English  translation  of  Dionis'  Treatise  on  Mid- 
wifery, London,  1718). 


ana  is  too  small,  the  egg  stops  and  can  get  no  farther,  but  shoots  forth 
and  takes  root  there ;  and  having  the  same  communication  with  the  blood 
vessels  of  the  tuba  that  it  would  have  had  with  those  of  the  womb,  had 
it  fallen  into  it,  is  nourished  and  grows  big  to  such  a  degree  that  the 
membrane  of  the  tuba,  being  capable  of  no  such  dilatation  as  that  of 
the  uterus,  breaks  at  last,  and  the  fetus  falls  into  the  cavity  of  the  abdo- 
men, where  it  sometimes  lies  dead  for  many  years,  and  at  other  times 
occasions  the  death  of  the  mothers  by  breaking  open  its  prison." 

This  description  includes  essentially  the  present  day  idea  of  the 
causation  of  ectopic  gestation,  except  that  Dionis  does  not  recognize  the 
existence  of  salpingitis  as  the  reason  for  an  obstruction  in  the  tube. 

The  first  recorded  case  of  operation  for  extra-uterine  pregnancy  in 
America  is  reported  by  Dr.  John  Bard,7  a  surgeon  of  New  York,  in  a 


io  EXTRA-UTERINE  PREGNANCY 

communication  to  the  journal,  "Medical  Observations  and  Inquiries." 
Dr.  Bard's  letter  is  dated  December  25th,  1759,  and  states  in  brief  the 
history  of  a  case,  in  which  a  Mrs.  Stagg,  28  years  of  age,  having  had 
one  child  without  any  uncommon  symptoms,  became  a  second  time  preg- 
nant. She  was  more  disordered  in  this  pregnancy  than  during  the  first, 
and  at  the  end  of  nine  months  she  had  some  labor  pains  but  no  flow  of 
water  or  other  discharge.  The  pains  soon  wore  off  and  there  remained 
a  large,  hard,  indolent  tumor  inclining  toward  the  right  side.  In  five 
months  she  conceived  again,  and  at  term,  after  a  short  and  easy  labor, 
was  delivered  of  a  healthy  child.  Five  days  after  delivery  she  was  seized 
with  a  violent  fever,  purging,  pain  in  the  tumor  and  fetid  sweats.  At 
the  end  of  the  nine  weeks,  as  the  tumor  developed  fluctuation,  Bard  made 
an  incision  through  the  right  rectus  muscle,  and  delivered  the  suppurating 
body  of  a  full  term  fetus.  The  wound  was  drained  and  the  patient  made 
a  good  recovery. 

"On  January  14th,  1791,  this  operation  was  performed  upon  this 
side  of  the  Atlantic  for  the  second  time,  the  subject  of  it  being  a  Mrs. 
Cocke,  the  wife  of  a  Virginia  planter.  The  operation,  which  was  done  by 
Dr.  William  Baynham,  a  country  physician,  was  entirely  successful. 
The  same  gentleman  operated  with  the  same  happy  result  upon  a  negro 
slave  on  February  6th,  1799.  This  was  the  fourth  American  gastrotomy 
for  the  removal  of  an  extra-uterine  fetus.  The  third  one  was  performed 
by  McKnight,  and  communicated  to  the  famous  Dr.  Lettsom,  by  Dr. 
Mease  of  Philadelphia,  and  published  in  1795.  Dr.  Baynham's  cases 
are  well  worth  attentive  study.  They  illustrate  the  intrepidity  and 
good  judgment  so  often  displayed  by  the  provincial  surgeon,  who,  sepa- 
rated by  long  distances  from  his  fellows,  often  has  to  act  in  the  greatest 
emergencies  without  the  counsel  which  he  may  earnestly  desire.  Almost 
a  quarter  of  a  century  passed  before  the  operation  was  repeated  in  this 
country.  On  the  6th  day  of  October,  1823,  it  was  again  performed  by 
Dr.  Wishart,  likewise  a  country  practitioner.  The  sixth  American  opera- 
tion was  performed  on  February  7th,  1846,  by  Dr.  A.  H.  Stevens  of 
New  York,  a  man  who  had  all  the  advantages  of  a  metropolitan  experi- 
ence."    (Parry.) 

From  this  time  on  interest  in  the  subject  grew,  three  varieties  of 
extra-uterine  pregnancy  being  generally  admitted  to  occur,  namely, 
tubal,  ovarian,  and  abdominal.  The  matter  rested  here  until  1824,  when 
Breschet  added  what  he  supposed  to  be  a  new  one,  that  which  was 
afterward  known  as  interstitial  pregnancy,  although  Schmitt  8  is  gen- 
erally accredited  with  publishing  the  first  authentic  case  of  this  variety. 

In  1837  appeared  the  very  important  monograph  of  Dezeimeris,9  in 


HISTORICAL  CONSIDERATIONS  n 

which  he  made  a  new  and  complex  arrangement  of  the  varieties  of  ectopic 
gestation,  with  a  careful  study  of  the  pathology. 

In  1S42  Campbell's  Memoir,  which  has  been  so  freely  quoted  here, 
was  published,  and  since  this  time  there  has  been  a  steady  increase  in 
the  volume  of  the  literature  on  this  matter,  most  of  the  essays  being 
valuable  contributions,  many  of  them  confused  and  showing  marked 
ignorance  of  the  basic  principles  involved,  and  a  few  teeming  with  mag- 
nificent collections  of  gorgeous  misstatements. 

Parry's  work,  by  far  the  best  produced  up  to  his  time,  and  one  which 
inspired  much  work  along  the  lines  of  pathology  and  treatment  of  extra- 
uterine pregnancy,  was  published  in  1876.  Of  this  book  Tait  says  "It  is 
at  once  remarkable  for  its  scholarly  research  and  fine  critical  sagacity. 
Where  he  has  got  astray,  has  chiefly  been  by  the  delusive  use  of  statistics, 
a  point  which  I  shall  deal  with  by  and  by." 

No  better  appreciation  of  the  amazing  advance  in  the  knowledge  of 
intrapelvic  pathology,  as  well  as  the  marvels  achieved  by  modern  surgery, 
can  be  obtained  than  by  a  close  reading  of  Parry's  book,  published  only 
a  little  more  than  four  decades  ago.  In  the  light  of  the  routine  hospital 
work  of  today,  the  facts  brought  out  in  this  monograph  seem  to  express 
the  thought  of  1476,  rather  than  1876;  and  to  compare  the  results  of 
treatment  then  and  now  must  lead  every  reader  to  mentally  add  another 
star  to  the  galaxy  that  crowns  those  two  pioneers,  to  whose  bold  and 
scholarly  efforts  we  owe  all  of  the  surgical  wonders  of  our  time,  Pasteur 
and  Lister. 

For  instance,  in  speaking  of  ruptured  extra-uterine  pregnancy,  Parry 
says  "The  gravest  accident  that  can  happen  to  the  victim  of  misplaced 
pregnancy  is  rupture  of  the  gravid  cyst.  This  is  attended  with  the  most 
alarming  symptoms,  and  frequently  terminates  in  death  within  a  short 
time.  The  almost  universal  opinion  of  the  profession  is,  that  this  ac- 
cident is  uniformly  fatal,  and,  if  not  so,  that  we  have  no  reliable  means" 
of  combating  its  dangers.  True,  some  have  raised  their  voices  and  used 
their  pens  to  advocate  surgical  interference,  but  as  yet  no  one  has  been 
bold  enough  to  hazard  an  operation  under  the  circumstances.  Operative 
interference  is  condemned  by  the  highest  authorities  upon  the  subject, 
and  he  who  would  subject  a  woman  under  these  circumstances  to  the 
dangers  of  gastrotomy  would  have  to  possess  the  courage  of  McDowell 
and  his  immediate  followers.  The  subject,  however,  is  worthy  of  care- 
ful investigation;  indeed,  this  is  one  of  the  most  practical  questions  which 
the  student  of  the  clinical  history  and  the  results  of  extra-uterine  preg- 
nancy can  investigate." 

Parry  was  able  to  collect  from  the  literature  500  cases  of  extra- 


12  EXTRA-UTERINE  PREGNANCY 

uterine  pregnancy  of  all  ages,  among  whom  366  died  and  163  recovered, 
a  mortality  of  67.20  per  cent.  In  the  list  of  causes  of  death,  rupture  of 
the  sac  claimed  174  victims,  or  53  per  cent  of  the  deaths.  These  figures 
should  in  themselves  be  sufficient  to  disprove  the  claims  of  those  who, 
even  today,  advise  expectant  treatment  in  these  cases. 

After  Parry,  came  what  Bovee  well  terms  the  housecleaning  work 
of  Lawson  Tait,10  who  so  definitely  established  the  pathology  and  treat- 
ment of  this  accident  that,  in  the  main,  his  views  are  still  those  accepted 
by  the  profession.  Curiously  enough  Tait  would  not  admit  the  possibility 
of  primary  ovarian  pregnancy,  considering  the  chance  of  its  occurrence 
so  remote  that  it  might  be  "regarded  as  likely  as  the  birth  of  a  blue  lion 
or  a  swan  with  two  necks,  like  a  heraldic  monstrosity — a  mere  patholog- 
ical curiosity."  Tait's  work  has  been  followed  by  the  modern  literature, 
which  is  still  too  closely  in  focus  to  be  regarded  from  the  viewpoint  of 
the  historian ;  although  an  account  of  the  epoch  making  essays  on  extra- 
uterine pregnancy  cannot  be  closed  without  mention  of  the  brilliant 
study  of  Werth  in  1887,  in  which  are  laid  down  the  principles  followed 
to  this  time  by  every  pathologist  engaged  in  the  study  of  specimens  of 
this  lesion. 

Ovarian  pregnancy  has  long  excited  the  interest  of  obstetricians,  and 
many  amusing  and  interesting  debates  have  arisen  concerning  its  possi- 
bility and  mechanism. 

The  first  case  so  diagnosed  was  that  of  Dr.  de  S.  Maurice,  communi- 
cated by  the  Abbe  de  la  Roque,  and  occurring  in  1682.  This  was  fol- 
lowed by  another  example  reported  in  1697.  Velpeau  in  1824  denied  the 
possibility  of  this  variety  of  ectopic  gestation,  though  it  was  recognized 
by  Dezeimeris. 

Tait,  as  has  been  shown,  waxed  satirical  regarding  the  matter,  and 
not  until  the  carefully  studied  case  of  Van  Tussenbroek  was  published, 
did  recognition  of  ovarian  pregnancy  become  universal. 

History  of  Treatment. — Laparotomy  for  the  removal  of  old  abdom- 
inal fetuses  dates  from  1500  as  has  been  described,  but  the  treatment 
of  early  rupture  of  a  tubal  pregnancy  is  quite  another  story. 

Here  again  the  critical  acumen  of  Parry  leads  him  to  conclusions  far 
in  advance  of  the  trend  of  contemporary  medical  thought.  Though  him- 
self not  a  surgeon,  his  summary  of  the  appropriate  treatment  of  cases 
of  early  rupture  is  masterly;  he  says  "Treatment  of  Rupture  of  the 
Cyst  in  the  early  Stages  of  Pregnancy.  In  speaking  of  the  result  of  this 
pitiless  termination  of  extra-uterine  gestation,,  it  was  stated  that  so  few 
recover  from  it,  that  all  hope  of  such  a  happy  result  is  to  be  dismissed  in 
considering  the  treatment.     No  doubt,  notwithstanding  the  statement  of 


HISTORICAL  CONSIDERATIONS  13 

Rogers  to  the  contrary,  a  few  women  have  recovered,  though  the  number 
is  very  small — so  small  that  when  one  is  called  to  a  case  of  the  kind,  it 
is  his  duty  to  look  upon  his  unhappy  patient  as  inevitably  doomed  to 
die,  unless  he  can  by  some  active  measures  wrest  her  from  the  grave 
already  yawning  before  her.  The  history  of  human  injury  and  disease 
presents  no  condition  parallel  to  this  one.  However  fatal  the  disorder, 
science  and  art  have  found  some  means  of  prolonging  life  or  'smoothing 
the  stormy  passage  to  the  grave.'  A  bleeding  vessel,  through  which 
the  red  stream  of  life  is  rushing  away,  can  be  ligated.  A  gangrenous 
limb,  which  is  destroying  its  possessor  by  sending  its  poisonous  emana- 
tions to  the  remotest  regions  of  his  body,  can  be  amputated.  A  cancerous 
breast,  which  is  sapping  the  vitality  of  its  victim  hour  by  hour,  can  be 
removed  with  the  prospect  of  temporary  relief.  An  aneurism,  that 
places  life  in  constant  jeopardy,  can  often  be  cured  by  proximal  or 
distal  ligation.  The  tumultuous  action  of  a  heart  organically  diseased 
may  be  quieted  till  nature  restores  the  balance,  after  which  the  person 
may  enjoy  a  long  and  even  a  useful  life.  Even  phthisis  now  counts  its 
many  cures;  but  here  is  an  accident  which  may  happen  to  any  wife  in 
the  most  useful  period  of  her  existence,  which  good  authorities  have 
said  is  never  cured,  and  for  which,  even  in  this  age  when  science  and 
art  boast  of  such  high  attainments,  no  remedy,  either  medical  or  surgical, 
has  been  tried  with  a  single  success.  From  the  middle  of  the  eleventh 
century,  when  Albucasis  described  the  first  known  case  of  extra-uterine 
pregnancy,  men  have  doubtless  watched  the  life  ebb  rapidly  from  the 
pale  victim  of  this  accident,  as  the  torrent  of  blood  is  poured  into  the 
abdominal  cavity,  but  have  never  raised  a  hand  to  help  her.  Surely  this 
is  an  anomaly,  and  it  has  no  parallel  in  the  whole  history  of  human 
injuries.  The  fact  seems  incredible,  for  if  one  life  is  saved  by  active 
interference,  it  may  be  triumphantly  pointed  to  as  the  first  and  only  in- 
stance of  the  kind  on  record.  In  the  whole  domain  of  surgery — for  we 
cannot  look  to  other  than  surgical  measures  under  the  circumstances — 
there  is  now  left  no  field  like  this.  In  this  accident,  if  in  any,  there  is 
certain  death.  How  often  do  we  see  persons  recover  from  injuries  which 
their  surgeons  tell  them  will  be  mortal,  jtf  they  do  not  submit  to  a  grave 
and  terrible  operation,  and  which  with  a  dogged  determination  they 
refuse  to  have  performed,  preferring  to  perish  rather  than  to  suffer  such 
grave  bodily  mutilation;  or  else,  with  a  keener  instinct,  they  foresee  a 
happier  result  and  get  well,  notwithstanding  the  evil  prognostications  of 
the  surgeon,  and  in  defiance  of  all  the  laws  which,  as  man  with  his  fallible 
knowledge  supposes,  govern  human  injuries.  But  in  rupture  of  an  extra- 
uterine fetal  sac,  in  the  early  stages  of  pregnancy,  a  whole  lifetime — a 


14  EXTRA-UTERINE  PREGNANCY 

whole  century — is  not  enough  to  enable  one  person  to  make  two'  errors 
in  regard  to  the  prognosis  of  this  accident.  The  only  remedy  that  can 
be  proposed  to  rescue  a  woman  under  these  unfortunate  circumstances  is 
gastrotomy — to  open  the  abdomen,  tie  the  bleeding  vessels,  or  to  remove 
the  sac  entire.  This  treatment  was  suggested  by  Dr.  W.  W.  Harbert,  in 
1849,  and  again  by  Dr.  Stephen  Rogers,  of  New  York,  in  a  paper  read 
before  the  American  Medical  Association  in  1866.  The  first  suggestion 
of  performing  gastrotomy  to  save  a  woman  dying  from  early  rupture  of 
the  cyst  came,  so  far  as  we  know,  from  our  countryman,  Dr.  Harbert, 
while  to  Rogers  belongs  the  credit  of  formulating  the  arguments  in 
favor  of  this  practice  and  bringing  them  prominently  before  the  pro- 
fession. Since  he  wrote  the  same  plan  of  treatment  has  been  advocated 
by  Meadows,  Heritt,  Greenhalgh,  and  Playfair,  in  a  discussion  before  the 
Obstetrical  Society  of  London.  Koberle,  Behier,  Schroder,  and  Atlee 
countenance  the  proceeding,  but  no  person  has  yet  performed  gastrotomy 
for  the  relief  of  this  accident.  The  great  impediment  to  the  adoption  of 
this  treatment  is  the  uncertainty  of  diagnosis.  It  should  be  remembered 
that  rupture  usually  occurs  before  the  end  of  the  fourth  month,  and 
that  in  many  of  these  cases  the  contents  of  the  cyst  are  discharged  and 
float  freely  in  the  blood  in  the  peritoneal  cavity.  It  is  also  an  established 
fact  that  in  early  rupture  the  most  severe  hemorrhage  occurs  in  those 
cases  in  which  the  contents  of  the  cyst  do  not  escape,  and  the  blood 
flows  from  an  orifice,  sometimes  so  minute  that  this  is  one  of  the  most 
singular  facts  known  in  connection  with  extra-uterine  pregnancy.  This 
and  the  well  established  fatality  of  the  accident  warrant  the  conclusion 
that  the  woman's  chances  of  life  will  not  be  lessened  by  enlarging  the 
opening  and  removing  the  ovum." 

Although  abdominal  section  was  first  suggested  in  the  treatment  of 
ruptured  tubal  pregnancy  by  Dr.  Harbert  in  1849,  the  honor  of  per- 
forming the  first  operation  for  this  emergency  went  to  Lawson  Tait  in 
1883.  Deaver  10  describes  the  event,  relating  that  Mr.  Tait  had  been 
earnestly  solicited  to  operate  for  this  condition  in  1881  by  a  physician 
who  had  correctly  diagnosed  a  case  of  rupture  with  internal  hemorrhage. 
He  refused,  and  the  patient  died  shortly  after.  Unfortunately  the  first 
patient  operated  on  died  also,  but  his  change  of  heart  was  complete  and, 
correctly  attributing  his  failure  in  the  first  case  to  faulty  technique,  he 
altered  his  method  and  continued  to  operate  upon  all  such  cases.  Of 
the  next  forty  patients  only  one  died.  Truly  a  brilliant  record,  which 
was  not  long  in  converting  the  medical  fraternity. 

It  is  interesting  to  note,  in  this  connection,  that  in  1882  two  of 
America's  foremost  gynecologists,  T.  Gaillard  Thomas  and  H.  J.  Gar- 


HISTORICAL  CONSIDERATIONS  15 

rigues,12  in  a  paper  read  before  the  American  Gynecological  Society 
strongly  advocated  the  use  of  electricity  in  cases  of  extra-uterine  preg- 
nancy, the  principle  being  to  destroy  the  life  of  the  ovum  by  a  strong 
galvanic  current  applied  to  the  enlarged  tube  via  the  vagina.  Both 
essayists  deprecated  operative  interference  in  these  cases  until  the  period 
of  the  viability  of  the  child,  when  cesarean  section  was  permissible.  In 
the  discussion  that  followed  the  opinions  of  the  fellows  generally  were 
in  accord  with  the  paper.  Even  so  late  as  1890  we  find  Howard  A. 
Kelly  13  making  the  statement,  "I  have  no  fault  to  find  with  those  who 
use  electricity  in  the  earlier  months,  while  holding  themselves  in  readiness 
to  perform  an  abdominal  section  upon  the  appearance  of  the  first  un- 
toward symptom.  It  is  well  adapted  to  those  cases  which  have  ruptured 
into  the  broad  ligament,  and  are  very  difficult  to  enucleate.  These  are 
cases  where  we  want  to  stop  the  growth  of  the  fetus  and  where  we  need 
not  be  in  haste  to  operate." 

The  first  American  operation  for  ruptured  ectopic  pregnancy  was 
performed  in  October  1883  by  Dr.  Charles  K.  Briddon  of  New  York. 
This  case  was  seen  in  consultation  by  T.  G.  Thomas,14  who  describes  it. 
The  patient  was  a  woman  of  twenty-eight,  who  had  borne  two  children, 
the  last  one  thirteen  months  before  her  present  illness.  She  developed 
the  signs  of  a  ruptured  ectopic  pregnancy,  and  Dr.  Briddon  made  a 
diagnosis  and  proved  its  correctness  by  performing  laparotomy  and  re- 
moving the  fetus  and  the  ruptured  tube.  The  patient  rallied  and  for  a 
time  did  well,  but  at  the  end  of  forty-seven  hours  succumbed  to  shock. 

To  illustrate  the  view  of  the  leaders  of  gynecological  thought  at 
this  time,  a  paragraph  from  this  same  paper  of  Thomas'  may  well  be 
quoted.  He  says  "The  growing  triumphs  of  abdominal  surgery  are  apt 
to  lead  to  the  conviction  that  laparotomy  should,  as  a  rule,  be  the  pro- 
cedure of  election  in  these  cases.  From  this  view  I  unqualifiedly  dissent. 
In  the  electrical  current  we  have  an  infanticide  agent  of  reliable  charac- 
ter." 

From  this  time  on  operative  interference  in  ectopic  pregnancy  has 
been  the  recognized  treatment,  although  in  1907  the  experiments  of 
Hunter  Robb  and  the  work  of  his  followers  tended  for  a  short  time 
to  delay  surgical  intervention.  Robb  severed  the  ovarian  and  uterine 
arteries  in  pregnant  bitches  and  found  that  practically  none  of  his  experi- 
mental animals  succumbed  to  hemorrhage.  From  this  basis  he  reasoned 
that  women  did  not  bleed  to  death  from  ruptured  tubal  pregnancies,  but 
did  die  from  the  attendant  shock,  and  that,  if  the  shock  were  properly 
combated,  the  patient  would  react  and  operation,  if  at  all  necessary, 
could  safely  be  performed  after  reaction  had  taken  place.    These  experi- 


16  EXTRA-UTERINE  PREGNANCY 

merits  and  the  very  definite  statements  of  Robb  and  Simpson  of  Pitts- 
burg had  a  profound  effect  on  the  profession  at  large,  and  the  so-called 
hibernation  treatment  became  common.  It  has  not  stood  the  test  of  time, 
however,  many  patients  being  lost  from  hemorrhage  while  the  surgeon 
waited  in  vain  for  the  expected  reaction,  and  this  plan  for  the  manage- 
ment of  these  cases  has  been  abandoned  to  a  considerable  extent. 

Immediate  laparotomy  is  the  rule  today,  although  some  operators  still 
prefer  to  observe  their  very  ill  patients  as  to  whether  they  are  gaining 
or  losing  ground,  before  resorting  to  surgical  measures  for  relief. 

LITERATURE 

1.  Bovee,  J.  W.     Ectopic  Pregnancy.    Am.  Jour.  Obst.,  1910.  61 1583. 

2.  Cornax,  M.     Sur  les  accouchements.     2:61. 

3.  Primerose,  J.    De  Mulierum  Morbis  et  Symptomatis  Libri  Quartus, 

1594.    4:316. 

4.  Calvo,  P.  B.     Histoire  de  l'Academie  Royale  des  Sciences,   1714. 

p.  29. 

5.  Dionis,  P.     Traite  general  des  accouchemens.     Paris,  1718.     p.  91. 

6.  Ibid.    A  General  Treatise  on  Midwifery.    Translated  by  Bell  et  al. 

London,  1719. 

7.  Bard,  J.     Medical  Observations  and  Inquiries.    London,  1764.  2:36. 

8.  Schmitt.     Beob.  K.K.  Med.-Chir.  Akad.  zu  Wien.     1801.     1  :$. 

9.  Dezeimeris,  J.  E.     Grossesses  extra-uterines.     Jr.  de  conn,  med.- 

chir.    Jan.,  1837. 

10.  Tait,  R.  L.    Lectures  on  Ectopic  Pregnancy  and  Pelvic  Hematocele. 

Birmingham,  1888. 

11.  Deaver,  J.  B.     Sajous'  Analytic  Cyclopedia  of  Practical  Medicine. 

1:184. 

12.  Thomas,  T.  G.,  and  Garrigues,  H.  J.     Tr.  Am.  Gyn.  Soc.    v.  7. 

13.  Kelly,  H.  A.    Discussions  Bait.  Gyn.  and  Obst.  Soc.     1890. 

14.  Thomas,   T.   G.     Extra-uterine   Pregnancy.     Tr.  Am.   Gyn.    Soc. 

1884.    9:161. 


CHAPTER  II 

DEFINITION,  FREQUENCY,  CAUSES 

Definition — Frequency — Race  Incidence — Age — The  Varieties  of  Extra-Uterine  Ges- 
tation— The  Relative  Frequency — The  Causes  of  Extra-uterine  Pregnancy — Ob- 
struction of  the  Tubal  Lumen  from  Without — Obstruction  of  the  Tubal  Lumen 
from  Within — Anomalies  of  the  Tubal  Lumen,  Accessory  Tubes,  etc.,  into  which 
the  Ovum  Falls — Decidual  Reaction  of  the  Tube — The  External  Migration  of 
the  Ovum — The  Cause  of  Ovarian  Pregnancy — The  Cause  of  Primary  Abdom- 
inal Pregnancy — Bibliography. 

Definition. — Extra-uterine  pregnancy  or  ectopic  pregnancy  or  ec- 
chyesis,  may  be  defined  as  that  condition  which  arises  when  a  fecundated 
ovum  lodges  and  imbeds  itself  in  any  situation  outside  the  cavity  of  the 
uterus,  nidation  proceeding  in  the  aberrant  site  for  a  variable  period. 

There  are  several  well  differentiated  varieties  of  this  lesion,  as  the 
ovum  is  arrested  and  develops  in  one  or  another  site,  the  varieties  being 
marked  by  differences  in  physical  signs,  in  symptoms,  in  terminations 
and  in  results,  as  well  as  the  varying  reactions  of  the  tissues,  in  which 
such  abnormal  implantation  occurs,  to  the  presence  of  trophoblastic 
activity. 

Frequency. — Statistics  regarding  extra-uterine  pregnancy  show  a 
constantly  increasing  frequency  of  this  condition.  The  older  text  books, 
those  written  before  1900,  give  a  varying  proportion  of  from  one  in 
five  hundred  to  one  in  twelve  hundred  pregnancies.  Winckel  saw  six- 
teen cases  in  twenty-two  thousand  births  and  Bandl  of  Vienna  saw  but 
three  among  sixty  thousand  births. 

By  contrast,  Wynne  reports  303  cases  of  ectopic  pregnancy  in  22,688 
patients  in  the  gynecological  clinic  of  Johns  Hopkins  Hospital,  an  inci- 
dence of  1.3  per  cent. 

These  statistics  are  all  presumably  valueless  in  estimating  the  actual 
frequency  of  ectopic  gestation,  because  while  some  were  compiled  from 
the  histories  of  obstetric  clinics  alone,  others,  as  those  of  Wynne,  show 
the  incidence  only  in  relation  to  gynecological  cases. 

In  order  to  ascertain  the  true  relation  of  the  occurrence  of  extra- 
uterine pregnancy  to  intra-uterine  gestation,  the  writer  obtained  the  to- 
tal number  of  cases  of  the  former  variety  admitted  to  the  hospitals  in  the 
City  of  Philadelphia,  during  the  year  19 18.    If  the  total  number  be  com- 

17 


18  EXTRA-UTERINE  PREGNANCY 

pared  to  the  number  of  births  registered  by  the  Bureau  of  Vital  Statistics 
for  the  same  time  and  covering  the  same  area,  an  absolute  ratio  is  estab- 
lished, at  least  for  one  large  city  during  one  year,  and  for  statistical  pur- 
poses it  is  fair  to  assume  that  this  ratio  remains  fairly  constant  from 
year  to  year.  During  191 8  there  were  admitted  to  all  the  hospitals  in  the 
corporate  limits  of  the  City  of  Philadelphia  169  cases  of  ectopic  gesta- 
tion. During  the  same  year  there  were  registered  by  the  Division  of 
Vital  Statistics  42,904  living  births  and  2,049  stiH  births,  a  total  of 
45,153  and  a  ratio  of  ectopic  gestation  to  full  time  intra-uterine  preg- 
nancy of  1  to  267  or  .0038  per  cent. 

These  figures  are  accurate  and  give  the  absolute  relation  of  extra-  to 
intra-uterine  pregnancy,  as  reported  to  the  hospitals  and  the  Bureau  of 
Health.  In  order  to  utilize  them  from  the  standpoint  of  scientific  com- 
parison, however,  it  is  necessary  to  make  certain  corrections.  Not  all 
cases  of  extra-uterine  pregnancy  are  admitted  to  hospitals,  some  dying 
at  home  under  a  mistaken  diagnosis,  and  some  recovering  without  hos- 
pital aid  or  surgical  interference.  Therefore  it  seems  proper  to  arbitra- 
rily add  10  per  cent  to  the  total  of  reported  cases  of  ectopic  pregnancy, 
to  allow  for  the  factor  of  error. 

Furthermore,  not  all  intra-uterine  pregnancies  go  to  term.  In  a 
careful  analysis  of  this  matter,  Hirst 2  concludes  that  there  is  one  abor- 
tion to  every  four  full  time  pregnancies. 

Abortion  and  miscarriage  are  not  reported  to  the  Division  of  Vital 
Statistics,  and  in  order  to  reach  the  proper  figures  in  this  regard,  it  be- 
comes necessary  to  add  one  fourth  the  total  number  of  births,  or  in  this 
instance,  11,288,  to  the  recorded  number,  in  order  to  include  in  the  sta- 
tistics of  intra-uterine  pregnancies  those  which  terminate  before  the 
viability  of  the  child. 

The  corrected  figures  for  the  City  of  Philadelphia  in  the  year  19 18 
would  then  read : 

Intra-uterine   pregnancies    56,441 

Extra-uterine   pregnancies    186 

Giving  a  ratio  of   1  to  303  or  .0033  per  cent. 

The  increased  frequency  of  ectopic  gestation  during  the  past  two 
decades  is  explained,  first,  by  the  fact  that,  as  more  cases  are  constantly 
being  accurately  diagnosticated  and  subjected  to  operative  relief,  and 
fewer  women  die  as  a  result  of  erroneous  diagnosis,  the  increase  is  to  a 
considerable  degree  a  fictitious  one  and  not  absolute;  second,  that, 
as  conservative  gynecological  operations  become  more  popular,  so  will 
subsequent  ectopic  gestation  become  more  common,  since  previous  pelvic 


DEFINITION,  FREQUENCY,  CAUSES  19 

operation  is  so  usual  an  event  in  the  history  of  these  cases.  Such  acces- 
sion in  number  is,  of  course,  an  absolute  increase  in  frequency  of  extra- 
uterine pregnancy.  De  Lee  states  that  the  condition  is  more  frequent 
in  city  than  in  country  practice,  but  this  may  be  due  to  the  more  accu- 
rate diagnostic  method  available  in  cities  and  the  more  general  hospitali- 
zation of  patients  in  urban  communities. 

Repetition  of  the  accident  in  the  same  tube,  and  not  uncommonly  in 
the  other  tube  in  the  same  individual,  has  been  reported,  and  intra- 
uterine and  extra-uterine  gestation  may  coexist. 

Race  Incidence. — In  the  United  States,  at  least,  race  seems  to  be  a 
negligible  factor  with  regard  to  the  occurrence  of  extra-uterine  preg- 
nancy. Statistics  vary  as  to  its  prevalence  among  whites  and  negroes,  ac- 
cording to  the  locality  from  which  the  figures  are  taken.  In  the  south 
and  along  the  Atlantic  seaboard  the  lesion  is  frequently  found  in  the 
colored  race.  (Wynne,  in  303  cases  studied  at  Johns  Hopkins  Hospital, 
found  202  to  be  among  the  white  race  and  10 1  occurred  in  negroes.) 
In  the  western  portion  of  the  country  there  are  but  few  recorded  cases 
among  negroes,  due,  naturally,  to  the  small  element  of  this  race  among 
the  population. 

Age. — Extra-uterine  pregnancy  being  solely  a  disease  of  the  child 
bearing  period,  its  age  incidence  is  necessarily  limited. 

Farrar's  3  statistics  in  a  series  of  262  cases  showed  that  the  ages 
ranged  from  seventeen  to  forty-two  years  and  63  per  cent  of  the  series 
were  between  the  ages  of  twenty-four  and  thirty-three  years  inclusive. 

Wynne  1  found  in  303  cases  61  per  cent  occurring  during  the  decade, 
twenty-four  to  thirty-three  years  inclusive.  In  the  writer's  series  of 
cases,  70  per  cent  occurred  in  this  decade. 

The  most  frequent  age  for  the  development  of  ectopic  gestation,  then, 
is  the  decade  between  twenty-four  and  thirty-three  years,  and,  as  most 
American  girls  marry  in  their  early  twenties,  it  follows  that  the  majority 
of  these  cases  occur  within  the  first  ten  years  of  married  life. 

This  fact  is  significant,  in  view  of  the  commonly  repeated  statement 
that  extra-uterine  pregnancy  occurs  most  commonly  after  a  prolonged 
period  of  sterility,  or  at  least  unfruitfulness. 

The  Varieties  of  Extra-uterine  Gestation. — An  ovum  may  be 
arrested  anywhere  in  its  passage  from  the  ovary  to  the  uterine  cavity, 
and  may  imbed  in  any  portion  of  the  genital  tract  distal  to  this  cavity; 
hence  the  several  varieties  of  ectopic  gestation  are  to  be  considered  solely 
in  relation  to  that  portion  of  the  genital  tract  in  which  the  aberrantly 
situated  ovum  imbeds  and  develops. 

This  classification  is  based  upon  the  original  point  of  implantation  of 


,20  EXTRA-UTERINE  PREGNANCY 

the  fertilized  ovum.  When  nidation  proceeds  at  the  point  of  first  arrest, 
it  is  designated  as  primary  extra-uterine  pregnancy ;  when  its  position  is 
changed  by  rupture  or  further  development,  it  is  designated  as  secondary. 
Beginning  at  the  uterus,  there  may  be  a  cornual,  interstitial,  or  apical 
pregnancy  when  growth  of  the  impregnated  ovum  proceeds  within  the 
thickness  of  the  uterine  wall  in  the  tubal  lumen;  isthmial,  when  the  arrest 
takes  place  in  the  constricted  isthmus  of  the  tube;  ampullar,  when  em- 
bryological  development  goes  on  in  the  expanded,  trumpet  shaped  am- 
pulla of  the  tube ;  tubo-ovarian  when  the  abnormal  site  is  at  the  fimbriated 
extremity  of  the  tube,  which  is  in  these  cases  attached  to  the  ovary  by 
preexisting  adhesions.     Ovarian  pregnancy,  the  rarest  of  the  primary 


Z                 ,~-     —r 

3 

<■''''    '/^:*V-:-':^---- 
-   & 

'■.}.:' 

%4  m 

<i 

\         \ 

f 
i 

1 

"1 
1 

«-Vr..d,     /-5=-«  t  ■-. 

y/                       3  a. »  . 

Fig.  5. — The  Sites  of  Implantation  of  the  Ovum  in  Extra-uterine  Pregnancy. 
i.  Interstitial  or  Cornual;  2.  Isthmial;  3.  Ampullar;  4.  Tubo-ovarian;  5.  Ovarian. 

forms,  occurs  when  the  ovum  is  fertilized  without  having  been  extruded 
from  the  graafian  follicle,  the  development  continuing  within  the  cortex 
of  the  ovary  (Fig.  5). 

Primary  abdominal  pregnancy,  when  the  ovum  is  fecundated  while 
free  in  the  peritoneal  cavity  and  implants  itself  upon  any  tissue  with 
which  it  may  come  in  contact,  is  a  theoretical  possibility.  In  the  older 
literature  this  variety  is  commonly  noted,  but  Werth  demonstrated  that 
the  clinical  cases  reckoned  as  such  were  all  tubal  in  their  origin. 

As  a  result  of  rupture  or  extrusion  from  the  original  site,  the  primary 
forms  may  undergo  changes  in  site,  development  going  on  to  greater  or 
less  degree  in  the  secondary  location.  Thus  an  interstitial  pregnancy 
may,  by  muscular  action,  be  forced  into  the  uterine  cavity  and  grow  as  a 
secondary  intra-uterine  pregnancy,  or,  it  may,  in  common  with  any  of 
the  tubal  forms,  become  abdominal,  that  is,  either  the  fetus  alive,  is  ex- 


Interstitial  ....     may  become 


Tubal  .,     .     ;.      .     may  become 


DEFINITION,  FREQUENCY,  CAUSES  21 

truded  from  a  rupture  in  the  sac,  the  placenta  continuing  to  develop  in 
its  original  site,  or  the  entire  ovum  may  escape  into  the  abdominal  cavity, 
the  placenta  becoming  reimplanted  on  some  vascular  intra-abdominal 
tissue  with  continued  growth  of  the  embryo.  The  same  change  may 
take  place  in  primary  ovarian  pregnancy. 

The  following  table,  taken  from  Kelly,4  clearly  shows  the  changes 
which  each  of  the  primary  forms  may  undergo. 

Primary  Forms  Secondary  Forms 

'Intra-uterine, 
Abdominal, 
Intraligamentary. 

'Abortion,   ■ 
Tubo-abdominal, 
Tubo-ovarian, 
Abdominal, 

Llntraligamentary. 

Ovarian       ....     may  become     ....  Abdominal. 

The  Relative  Frequency  of  the  various  forms  of  ectopic  pregnancy 
is  somewhat,  difficult  to  determine,  as  statistics  are  usually  mute  on  this 
point.  The  interstitial  variety  appears  to  be  the  rarest  of  the  tubal 
forms. 

Rosenthal  5  found  it  to  occur  in  30  per  cent  of  1324  cases  of  ectopic 
pregnancy  collected  by  him.  This  estimate  seems  very  high.  Weim- 
brenner  6  collected  only  35  cases  up  to  1904.  The  old  analysis  of  J  J 
cases  observed  by  A.  Martin  (quoted  by  Kelly4)  is  as  follows: 

Ampullar   48 

Isthmial . . 8 

Interstitial    1 

Intraligamentary 7 

Tubo-ovarian 6 

Tubo-abdominal 3 

Ovarian 1 

Undetermined    3 

In  a  study  of  106  cases,  Oastler  7  found  the  following  sites : 

Inner  half  of  tube  (isthmial)   38 

Outer  half  of  tube  (ampullar)   32 

Interstitial    2 

Ovarian    2 

Not  obtainable   32 


22  EXTRA-UTERINE  PREGNANCY 

A  study  of  1 17  cases  by  Foskett  8  shows  the  pregnancy  to  have  been : 

Ampullar  in 52 

Isthmial  in 64 

Interstitial   in    1 

These  statistics  show  considerable  variation;  but  a  survey  of  them 
demonstrates  the  fact  that  isthmial  pregnancy  is  slightly  more  common 
than  ampullar,  interstitial  is  rare,  as  is  abdominal  of  the  various  types, 
while  ovarian  pregnancy  is  very  seldom  met  with.  The  tubes  are  af- 
fected with  almost  equal  relative  frequency,  though  there  is  a  widespread 
belief  that  the  right  is  more  commonly  involved.  This  is  in  error,  as 
shown  by  the  following  review  of  case  groups : 


Tube  Affected 

OASTLER 

FARRAR 

BOVEE 

FRANK 

FOSKETT 

WILLIAMS 

Total 

Right 

Left 

54 
46 

2 

I48 

I4O 

I 

28 
31 

23 
29 

43 
74 

69 

53 
1 

365 

373 

4 

Both 

The  Causes  of  Extra-Uterine  Pregnancy. — The  causative  factors 
leading  to  the  ectopic  implantation  of  an  ovum  are  of  various  natures, 
usually  indeterminate  in  the  individual  case,  and  discussion  and  specula- 
tion upon  these  details  has  developed  an  enormous  literature,  but  with 
no  specific  pathology  as  yet  remaining  unchallenged,  applicable  to  the 
condition  as  a  whole. 

Out  of  the  mass  of  theory  and  clinicopathological  facts  presented,  a 
series  of  factors,  any  one  of  which,  or  a  combination  of  several,  when 
operative,  may  result  in  ectopic  implantation  of  the  ovum,  have  been 
generally  accepted  as  true  causative  agents.  The  difficulties  in  arriving 
at  the  true  cause  lie  largely  in  the  fact  that  the  pathologist  is  rarely  able 
to  make  his  observations  until  the  condition  has  progressed  so  far  that 
the  original  anatomical  features  have  been  obliterated,  or  so  altered  that 
the  recognition  of  the  factors  predisposing  to  the  starting  or  development 
of  the  tubal  pregnancy  are  obscured  or  rendered  imperceptible.  The 
importance  of  careful  study  of  all  specimens  with  regard  to  the  etiology 
is  well  brought  out  by  Williams  9  when  he  says  that,  despite  the  existence 
of  seemingly  insuperable  difficulties,  it  is  our  duty  to  continue  our  re- 
searches in  this  almost  unknown  field,  for  not  until  we  clearly  understand 
the  predisposing  factor,  or  factors,  which  bring  about  an  ectopic  gestation, 
can  we  hope  to  institute  a  more  intelligent  preventive  treatment  that 
will  result  in  a  lessened  morbidity,  or  at  least  a  lessened  mortality.     In 


DEFINITION,  FREQUENCY,  CAUSES  23 

general,  however  observers  may  differ  as  to  the  cause  of  ectopic  preg- 
nancy, it  is  universally  held  that  this  cause  must  lie  in  some  interference 
with  the  passage  of  the  ovum  from  the  fimbriated  extremity  of  the  tube 
to  the  uterine  cavity. 

Such  interferences  may  result  from : 

1.  Obstruction  of  the  tubal  lumen  from  without. 

2.  Obstruction  of  the  tubal  lumen  from  within. 

3.  Anomalies  of  the  tubal  lumen,  accessory  tubes,  etc.,  into  which 

the  ovum  falls  and  can  henceforward  be  propelled  no  further. 

4.  Decidual  reaction  in  the  tube. 

5.  The  growth  of  a  fertilized  ovum  outside  the  tube  to  such  ex- 

tent that,  when  the  ovum  does  finally  enter  the  tube,  its  size 
precludes  its  transit  through  the  lumen  (external  emigration 
of  ovum). 

1.  Obstruction  of  the  Tubal  Lumen  from  Without. — Taking 
up  these  primary  causes  in  detail,  the  obstruction  of  the  tubal  lumen  from 
without  may  originate  in : 

a.  Peritubal  adhesions,  causing  strictures  or  kink. 

b.  Constriction  resulting  from  presence  of  a  tumor  of  neighbor- 

ing organs,  as  a  cornual  fibroma,  ovarian  or  parovarian  cysts, 
etc. 

(a)  Peritubal  adhesions  are  of  frequent  occurrence,  being  the  end 
result  of  a  perisalpingitis,  whose  etiology  may  be  either  of  intratubal 
origin  or  an  inflammation  by  contiguity  following  appendicitis,  diverticu- 
litis or  a  general  peritonitis  from  rupture  of  a  gastric  or  intestinal  ulcer. 

A  case  of  the  writer's  well  illustrates  this  etiology.  A  woman  of 
36,  who  had  previously  suffered  from  a  violent  suppurative  appendicitis 
with  long  continued  abdominal  drainage,  developed  an  ectopic  pregnancy 
in  the  right  tube,  which  ruptured  at  about  the  fourth  week  of  pregnancy. 
The  tube  was  removed,  the  patient  making  an  uneventful  convalescence. 
On  examination  of  the  specimen,  the  pregnancy  was  found  to  be  am- 
pullar in  type,  the  rupture  having  taken  place  on  the  superior  aspect. 
The  entire  tube  was  bound  down  by  dense  adhesions,  and  just  distal  to 
the  gestation  sac  there  was  found  a  sharp  angulation  of  the  tube,  the 
kink  being  held  securely  in  place  by  a  broad,  firm  band  of  adhesion.  On 
section  there  was  nowhere  apparent  any  evidence  of  endosalpingitis. 

Conservative  gynecological  operations,  performed  for  the  relief  of 
sterility  or  to  cure  a  train  of  symptoms  dependent  on  such  peritubal 


24  EXTRA-UTERINE  PREGNANCY 

adhesions,  are  in  themselves  strong  predisposing  factors  to  the  subse- 
quent development  of  ectopic  pregnancy. 

Thus  Giles10  reports  125  cases  wherein  conservative  operations  had 
previously  been  performed.  Of  these,  33  or  26  per  cent  became  pregnant 
later,  and  of  the  pregnancies,  eignt  or  24  per  cent  were  extra-uterine. 

In  Norris' 1X  series  of  68  cases,  two  were  subsequently  operated  upon 
for  ectopic  pregnancy,  and  Norris  pertinently  remarks  that,  if  tubal 
pregnancy  is  particularly  prone  to  follow  conservative  operations,  this 
factor  must  be  taken  into  consideration  in  all  conservative  operations 
on  married  women  of  child  bearing  age. 

(b)  Constriction  resulting  from  pressure  of  a  tumor  of  neighboring 
structures,  without  inflammatory  changes  in  the  tube.  Such  purely 
mechanical  obstruction  of  the  lumen  of  the  tubes  is  a  well  known  cause 
of  tubal  pregnancy,  although  clinically  uncommon.  A  typical  case  is 
reported  by  Gardner.12  Gardner  studied  one  case  of  tubal  pregnancy, 
which  was  associated  with  a  large  uterine  fibroid,  and  the  pregnant  tube 
was  found  crowded  down  in  the  pelvis,  under  the  tumor.  Microscopi- 
cally as  well  as  macroscopically  there  were  no  evidence  of  any  present 
or  past  inflammatory  change  whatever. 

2.  Obstruction  of  the  Tubal  Lumen  from  Within  seems  in 
the  last  analysis  to  underlie  the  vast  majority  of  all  tubal  pregnancies. 
It  has  been  definitely  learned  that  the  direction  of  the  ciliary  current  in 
the  tube  is  toward  the  uterus,  the  function  of  the  cilia  being  to  assist 
the  peristaltic  action  of  the  tubal  musculature  to  promote  the  transit  of 
the  ovum  to  the  uterine  cavity.  Recent  observations  render  it  almost  a 
certainty  that  fertilization  of  the  ovum  normally  occurs  in  the  tube, 
and  if,  therefore,  any  marked  diminution  in  the  size  of  the  tubal  passage- 
way has  taken  place,  or  if  the  cilia  have  been  destroyed  by  inflammatory 
process,  there  may  easily  result  a  temporary  arrest  of  the  fecundated 
ovum  at  the  point  of  greatest  resistance  to  its  passage.  This  arrest, 
acting  for  but  a  short  time,  will  permit  the  rapidly  growing  embryo  to 
attain  such  dimensions  that  under  no  circumstances  could  it  penetrate 
the  constricted  area,  even  though  tubal  peristaltic  contraction  becomes 
very  powerful. 

The  most  common  morbid  process  in  the  production  of  strictures  in 
the  tube  or  destructions  of  its  epithelial  coat  is  some  form  of  salpingitis, 
notably  gonorrhea,  by  reason  of  the  prevalence  of  this  infection. 

Williams  9  states  definitely  that  in  all  his  specimens  evidences  of  an 
inflammatory  reaction,  which  had  preceded  the  onset  of  the  ectopic 
gestation,  were  demonstrable,  and  further,  these  inflammatory  changes 
in  all  cases  where  both  tubes  were  removed  were  shown  microscopically 


DEFINITION,  FREQUENCY,  CAUSES  25 

to  be  bilateral,  and  diverticula  were  present,  not  only  in  the  tube  which 
lodged  the  ovum,  but  also  in  the  opposite  one. 

Williams  holds  that  in  such  cases  of  old  salpingitis  there  are  present 
epithelial  lined,  false  diverticula,  open  at  the  distal  and  closed  at  the 
mesial  end,  these  diverticula  being  formed  by  a  coalescence  and  cohesion 
of  the  tubal  mucosa.  The  complete  or  partial  absence  of  cilia,  or  the 
infiltration  and  alteration  of  the  tubal  wall,  resulting  from  inflammatory 
change,  as  a  consequence  of  which  peristalsis  is  impeded,  are  contributing 
factors,  but  are  in  themselves  insufficient  to  produce  an  absolute  barrier 
to  the  passage  of  the  ovum.  If,  however,  the  ovum  enters  one  of  the 
false  diverticula,  closed  at  the  mesial  end,  its  progress  is  effectually 
checked. 

This  view  as  to  causation  is  strongly  upheld  by  Opitz,13  who,  on 
making  serial  sections  of  the  tubes  in  23  cases  of  ectopic  pregnancy, 
found  these  canals  or  false  passages  present  in  every  instance. 

The  severity  of  the  inflammatory  change  in  the  tube  and  the  progress 
made  toward  healing  of  the  lesion  are  important  with  respect  to  the  eti- 
ology of  tubal  pregnancy.  In  a  well  considered  article  Mall 14  points 
out  that,  if  the  ovum  within  the  tube  contains  a  normal  embryo,  there 
is  but  little  adjacent  inflammation;  but  if  it.  contains  a  pathological 
embryo,  the  changes  in  the  tubal  wall  are  usually  marked,  and  when  the 
ovum  is  well  disintegrated,  the  changes  are  still  more  pronounced.  Read 
in  the  other  way,  this  would  mean  that,  if  the  inflammatory  condition 
is  nearly  healed,  the  ovum  implants  itself  in  the  tube  and  grows  nor- 
mally; but  if  the  results  of  infection  are  still  pronounced,  the  ovum 
rapidly  disintegrates.  Such  an  inflammation  is  signalized,  not  only  by 
an  inflammatory  reaction  in  the  tubal  wall,  but  also  by  very  pronounced 
changes  within  the  tube  lumen,  the  most  common  of  which  is  a  hyper- 
trophy and  adhesion  of  the  tubal  folds,  the  so-called  follicular  salpingitis. 

This  observation  is  of  clinical  importance,  in  that  it  confirms  the 
view  that  in  the  presence  of  acute  or  subacute  salpingitis,  ectopic  preg- 
nancy does  not  occur,  while  it  does  take  place  when  the  inflammatory 
process  is  subsiding;  and  it  is  fair  to  assume  that,  had  the  ectopic  preg- 
nancy not  developed  at  this  time,  the  tube  would  probably  have  become 
completely  healed  within  a  few  years,  thus  permitting  the  fertilized  ovum 
to  reach  the  uterus. 

3.  Anomalies  of  the  Tubal  Lumen,  Accessory  Tubes,  etc., 
into  which  the  ovum  falls.  4.  Decidual  Reaction  in  the  Tube. — • 
Congenital,  as  distinguished  from  postinflammatory  anomalies  of  the 
tube,  are  regarded  by  many  investigators  as  being  the  chief  cause  of 
ectopic  pregnancy,  especially  if  the  existence  of  rudimentary  miillerian 


26  EXTRA-UTERINE  PREGNANCY 

tissue  in  the  tubal  wall  be  considered  as  a  congenital  anomaly.  Web- 
ster 15  first  laid  down  the  rule  that  the  ovum  always  imbeds  in  mullerian 
tissue.  When  the  hypothesis  was  first  formulated  he  held  that  all  ectopic 
pregnancies  were  primarily  tubal,  but  when  the  indisputable  fact,  that 
primary  ovarian  pregnancy  could  and  did  occur,  was  brought  to  his 
notice,  Webster  amplified  his  theory  to  include  such  a  happening  by 
stating  that  mullerian  rests  could  occur  in  the  ovary,  and  that  ovarian 
pregnancy  must  take  place  in  such  rest.  This  theory  does  not  explain 
the  development  of  primary  abdominal  pregnancy,  but  no  really  authen- 
tic case  of  this  variety,  which  has  withstood  all  criticism,  has  been  re- 
corded. 

Hirst  and  Knipe 16  report  a  case  which  seems  to  meet  all  the  re- 
quirements, but  as  the  tube  and  ovaries  were  not  removed  at  operation 
and  hence  not  subjected  to  microscopical  study,  the  case  has  been  at- 
tacked. Therefore,  inasmuch  as  primary  peritoneal  imbedding  has  not 
been  satisfactorily  demonstrated,  Webster's  theory  is  not  weakened 
thereby. 

This  hypothesis,  reduced  to  its  lowest  terms,  is  that  under  certain 
conditions  an  ovum  may  imbed  in  an  aberrant  site  because,  and  only 
because,  that  site  contains  cells,  originally  derived  from  the  mullerian 
ducts,  which,  having  passed  through  a  stage  of  evolution,  later  revert 
to  their  original  type  and  reacquire  their  genetic  function  or  the  property 
of  forming  decidua. 

This  hypothesis  has  been  modified  and  advanced  again  by  Huff- 
man,17 who  states  as  his  theory  that  ectopic  pregnancy  is  determined 
by  an  anomalous  imbedding  area.  At  present  it  is  impossible  to  recog- 
nize the  anatomical  factors  which  are  necessary  to  an  imbedding  area, 
but  it  may  be  assumed  that  the  special  tissue  may  become  misplaced  dur- 
ing the  development  of  the  tubes  and  uterus  from  the  mullerian  ducts. 
There  is  a  mutual  relationship  of  imbedding  area  and  fecundated  ovum. 

In  a  later  article  18  this  author  states  that  he  has  examined  68  speci- 
mens of  tubal  pregnancy,  and,  in  spite  of  the  difficulties  of  examining 
torn  and  sometimes  incomplete  material,  he  has  found  malformations 
in  54  per  cent  of  them.  This  evidence,  besides  the  negative  findings  in 
regard  to  any  obstruction  or  inflammation,  is  sufficient  to  warrant  the 
establishment  of  the  anomalous  imbedding  area  theory,  in  Huffman's 
opinion  the  most  logical  of  all  the  explanations  for  ectopic  pregnancy. 

Both  Webster's  and  Huffman's  hypotheses  are  attractive,  but  unsat- 
isfactory for  certain  cases,  first,  in  that  it  has  been  shown,  as  pointed 
out  by  Williams,  that  the  decidua  does  not  play  nearly  so  important 
a  part  in  tubal  pregnancy  as  was  formerly  supposed;  second,  that  it 


DEFINITION,  FREQUENCY,  CAUSES  27 

does  not  account  for  the  very  many  specimens,  indeed  in  the  opinion 
of  the  writer,  the  great  majority,  wherein  marked  evidence  of  preexisting 
tubal  inflammation  with  destruction  of  mucosa,  inflammatory  diver- 
ticula, obstructions  by  exudate,  etc.,  are  associated  with  tubal  pregnancy, 
with  a  total  absence  of  any  demonstrable  anomalous  imbedding  area. 

Concerning  Huffman's  views  that  malformation  of  the  tubes,  ac- 
cessory ostia,  congenital  diverticula,  etc.,  are  responsible,  it  is  not  quite 
clear  just  why  the  presence  of  such  malformation  should  predicate  the 
existence  of  primitive  miillerian  tissue.  Further,  if  this  hypothesis  were 
true,  it  should  logically  be  expected  that  most  cases  of  ectopic  pregnancy 


toad  cht 

n't of/c  v>ac 


UfefiM<? 
enti  of   ~~ 
tvbt 


Tumor 


Ouanj  with 
Corpus  Luteum 


Fi'mbi 


Fig,    6. — Polypoid    Chondrofibroma    of    the    Fallopian    Tube,    Associated    with 
Tubal  Pregnancy.    From  Outerbridge. 

should  occur  in  primiparae,  with  whom  decidual  reaction  is  most  in- 
tense, whereas  the  reverse  is  the  fact. 

5.  The  External  Migration  of  the  Ovum. — External  migra- 
tion of  the  impregnated  ovum  from  its  graafian  follicle,  across  the  peri- 
toneal cavity,  to  enter  the  opposite  tube,  the  tube  on  the  same  side  being 
absent  or  impervious,  has  been  advanced  as  a  cause  of  tubal  pregnancy % 
As  an  etiological  factor  this  phenomenon  does  not  seem  to  be  of  much 
importance. 

Besides  this  group  of  usual  causes,  there  are  recorded  occasional 
cases  due  to  other  factors.  Tumors  of  the  tube  are  found  sometimes 
in  definite  relationship  to  this  lesion.  In  a  case  of  Outerbridge  19  there 
was  found  in  a  tube  removed  on  account  of  an  early  tubal  pregnancy,  a 
small,  somewhat  papillary  growth  practically  filling  the  lumen,  just 
proximal  to  the  placental  area.     Microscopic  examination  of  the  tumor 


28  EXTRA-UTERINE  PREGNANCY 

showed  it  to  be  a  somewhat  degenerated  chondrofibroma,  which  had  been 
connected  to  the  tubal  wall  by  a  narrow  pedicle.     (Figs.  6,  7,  8.) 

A  similar  case,  of  a  pedunculated,  submucous  fibroma,  measuring 
about  4.5  x  3  inches,  situated  just  at  the  tubo-uterine  opening,  which  is 
partly  occluded,  is  reported  by  Wettergren.20  This  tumor  was  associ- 
ated with  a  tubal  pregnancy,  which  the  author  considered  in  all  proba- 
bility due  to  the  partial  obstruction  of  the  tube  by  the  tumor. 


WikU 


Cattii^qe 


"Tufnof 


Tube  Li/mat 


Fig.  7. — Chondrofibroma   of   Fallopian   Tube.    From   Outerbridge. 

Tubal  polyps  were  ascribed  as  common  causal  agents  by  the  earlier 
writers,  but  subsequent  investigations  have  proved  them  to  be  of  infre- 
quent occurrence.  Cases  have  been  reported  by  Beck,  Breslau,  Leopold 
(two  cases)  and  Wydn,  all  of  whom  discuss  the  possibility  of  the  tumor 
having  formed  a  mechanical  hindrance  to  the  entrance  of  the  ovum  into 
the  uterus.  In  several  of  these  cases  a  distinct  decidual  reaction  was 
present,  and  Ahlfeld  indeed  has  advanced  the  contention  that  these  polyps 
represent  merely  proliferations  of  tubal  decidua,  secondary  to  the  preg- 
nancy, and  are  therefore  not  to  be  considered  a  causative  factor  in  the 
localization  of  this  in  the  tube  (Outerbridge  19)-. 


DEFINITION,  FREQUENCY,  CAUSES  29 

There  are  several  other  possible  causal  agencies,  all  of  which  are 
purely  conjectural  but  of  much  interest,  as,  for  example,  the  view  that 
monstrous  or  deformed  ova  are  themselves  responsible  for  their  abnor- 
mal imbedding,  since  they  do  not  possess  the  required  motility  to  prog- 
ress along  the  tube.  As  the  motility  of  the  young  ovum  has  not  been 
demonstrated  to  exist,  this  view  cannot  as  yet  be  supported.  Again,  it 
is  thought  by  some  observers  that  the  ovum  in  transit  through  the  tube 
derives  its  nutriment  from  some  tubal  secretion,  and  that,  under  certain 
conditions,  the  tube  may  secrete  substances  toxic  to  the  ovum,  which  is 


Fig.  8. — Chondrofibroma  of  Fallopian  Tube.    From  Outerbridge. 

thereby  impaired  as  to  its  vitality  and  ability  to  progress  toward  the 
uterus. 

Schil  21  advances  a  new  theory  as  to  the  causation  of  extra-uterine 
pregnancy,  believing  that  the  essential  factor  is  a  failure  of  the  unstriped 
muscle  fibers  of  the  tube  to  contract,  so  that  the  ovum  does  not  pass  into 
the  uterus.  What  the  factors  are  that  prevent  the  contraction  is  not 
stated,  and  the  observation  lacks  confirmation. 

In  summing  up  the  probable  causes  of  ectopic  gestation,  it  is  true 
that  no  one  or  even  several  causative  agents  have  been  satisfactorily 
demonstrated.  From  his  own  observation,  however,  and  from  a  study 
of  the  literature,  it  is  the  opinion  of  the  writer  that  the  usual  cause  is  the 
widely  accepted  and  simple  one  of  some  mechanical  arrest  of  the  fecun- 


3o  EXTRA-UTERINE  PREGNANCY 

■ 

dated  ovum  during  its  tubal  journey,  and  that  such  arrest  is  most  com- 
monly brought  about  by  the  end  results  of  tubal  inflammation  or  by 
pressure  from  neighboring  neoplasms. 

The  readiness  of  the  young  ovum  to  implant  itself  is  shown  by  the 
rapidity  with  which  secondary  implantation  takes  place  when  a  living 
ovum  is  extruded  from  a  tube,  either  by  rupture  or  tubal  abortion.  This 
is  well  illustrated  by  a  recent  case  occurring  in  the  writer's  clinic.  A 
woman  of  32,  who  had  borne  one  child,  developed  the  usual  signs  of  a 
ruptured  ectopic  pregnancy.     She  reacted  from  the  initial  traumatism 


Fig.  9. — Secondary  Implantation  of  an  Ovum  on  a  Knuckle  of  the  Ileum,  Ten 
Days  after  the  Rupture  of  a  Tubal  Pregnancy   (author's  case). 

and  was  kept  at  home  for  six  days,  when,  symptoms  of  intestinal  ob- 
struction supervening,  she  was  referred  to  the  Frankford  Hospital.  On 
examination  there  was  found  a  tympanitic  abdomen,  with  obstruction  to 
the  passage  of  feces,  though  flatus  was  expelled.  Douglas'  pouch  was 
bulging  and  doughy.  On  operation  there  was  found  a  ruptured  tubal 
pregnancy,  isthmial  in  character,  of  the  right  tube.  The  ovum,  1  inch 
in  diameter,  had  imbedded  itself  in  the  angle  of  a  coil  of  ileum,  and  in 
six  days  had  become  so  firmly  attached  that  the  bowel  was  angulated 
and  obstructed,  and  the  villi  had  so  deeply  entrenched  themselves  that, 
upon  separation  of  the  ovum  from  the  intestine,  the  mucosa  of  the  bowel 
was  exposed,  with  free  hemorrhage  necessitating  suture.  (Fig.  9.) 
In  general,  then,  the  inflammatory  theory  of  the  causation  of  ectopic 


DEFINITION,  FREQUENCY,  CAUSES  31 

pregnancy  should  receive  first  consideration.  Further  observations 
along  this  line  will  be  awaited  with  the  greatest  interest. 

The  Cause  of  Ovarian  Pregnancy. — This  rare  and  interesting 
variety  of  ectopic  gestation  has  not  been  reported  in  sufficient  num- 
bers to  formulate  any  specific  cause,  histologically  demonstrable.  Leo- 
pold 22  has  suggested  that,  in  a  certain  proportion  of  cases,  a  centrally 
located  follicle  may  rupture  into  a  more  superficially  located  one,  the 
ovum  in  the  former  not  being  expelled,  but  being  fertilized  in  its  original 
location  by  a  spermatozoon,  which  has  gained  access  through  the  super- 
ficial follicle. 

Hewetson  and  Lloyd  23  believe  that,  after  fertilization,  the  phagocytic 
ovum  may  burrow  into  another  or  deeper  portion  of  the  ovary.  Norris  24 
holds  the  spermatozoon  finds  its  way  into  a  recently  ruptured  graafian 
follicle  and  fertilizes  the  ovum  in  situ.  In  connection  with  Webster's 
decidual  reaction  theory,  as  applied  to  ovarian  pregnancy,  Norris  points 
out  that,  in  the  cases  of  this  condition  reported  up  to  1890,  but  few  are 
found  that  record  the  presence  of  decidua-like  cells,  and  in  these  the 
identification  of  the  latter  is  somewhat  doubtful.  Having  not  had  the 
opportunity  of  studying  a  specimen  of  ovarian  pregnancy,  the  writer  has 
no  personal  opinion  as  to  its  causation. 

The  Cause  of  Primary  Abdominal  Pregnancy,  like  its  very  existence, 
remains  in  obscurity  and  requires  no  further  mention. 


LITERATURE 

1.  Wynne,  H.  M.  N.    Bui.    J.  Hopk.  Hosp.,  1919,  30:15. 

2.  Hirst,  B.  C.     Textbook  of  Obstetrics.     Philadelphia. 

3.  Farrar,  L.  K.  P.    An  Analysis  of  309  Cases  of  Ectopic  Gestation. 

Am.  Jr.  Obst.     1919.    79  733- 

4.  Kelly,  H.  A.     Operative  Gynecology.     New  York,  1902.     2  434. 

5.  Rosenthal.    Ein  Fall  Intramuraler  Schwangerschaft.     Centrbl.  f. 

Gyn.     1896.    20:1297. 

6.  Weimbrenner.     Uber  Interstitielle  Schwangerschaft.     Ztschr.   f. 

Gebh.  u.  Gyn.     1904.    51:57. 

7.  Oastler,  T.  R.     Ectopic  Pregnancy.     Surg.   Gyn.   Obst.      1917. 

24:224. 

8.  Foskett,  E.    Am.  Jr.  Obst.    1916.    74:232. 

9.  Williams,    C.    D.      Etiology   of   Ectopic  Gestation.      Surg.    Gyn. 

Obst.    1908.    7:519. 


32  EXTRA-UTERINE  PREGNANCY 

10.  Giles,  A.  E.     A  Study  of  the  After  Results  of  Abdominal  Opera- 

tions on  the  Pelvic  Organs.     Jr.  Obst.  Gyn.  Brit.  Emp.     1910. 

17,  153- 

11.  Norris,   C.   C.     Gonorrhea  in  'Women.      Philadelphia,    1913.     p. 

307. 

12.  Gardner,  W.  S.     The  Cause  of  Tubal  Pregnancy.     West  Virg. 

Med.  Jr.     1918.     12 :37c 

13.  Opitz.    Ztschr.  f.  Gebh.  u.  Gyn.     1903.    b.  48. 

14.  Mall,  F.  P.     The  Cause  of  Tubal  Pregnancy  and  the  Fate  of  the 

Enclosed  Ovum.    Surg.  Gyn.  Obst.     1915.    21  1289. 

15.  Webster,  J.  C.    Ectopic  Pregnancy.    Edinburgh,  1895. 

16.  Hirst,  B.  C,  and  Knipe,  N.     Primary  Implantation  in  an  Ovum 

in  the  Pelvic  Peritoneum.     Surg.  Gyn.  Obst.     1908.     7:456. 

17.  Huffman,  O.  V.     Ectopic  Pregnancy  Associated  with  Anomalies 

of  the  Fallopian  Tubes.    Surg.  Gyn.  Obst.     1913.     16:548. 

18.  ■ A  Theory  of  the  Cause  of  Ectopic  Pregnancy.     Jr.  Am. 

Med.  A.     1913.    61:2130. 

19.  Outerbridge,  G.  W.     Polypoid  Chondrofibroma  of  the  Fallopian 

Tube  Associated  with  Tubal  Pregnancy.     Am.  Jr.  Obst.     19 14. 
70:173. 

20.  Wettergren.     Gros  polype  fibromyomatique  de  la  trompe,  decou- 

vert  en  cours  d'une  operation  de  grossesse  tubale.     Nord.  Med. 
Ark.     1901.     34:1.     Quoted  by  Outerbridge. 

21.  Schil,  M.     Jr.  de  Med.  de  Paris.     1914.     No.  17. 

22.  Leopold.    Arch.  f.  Gyn.     1882.     19:210.    Quoted  by  Norris. 

23.  Hewetson  and  Lloyd.    Brit.  Med.  Jr.     1906.     568. 

24.  Norris,  C.  C.     Primary  Ovarian  Pregnancy.     Surg.  Gyn.  Obst. 

1909.    9:123. 


CHAPTER  III 

THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY 

Termination  by  Resorption  of  the  Ovum — Death  of  the  Embryo  with  the  Formation 
of  Tubal  Mole — Tubal  Abortion — Rupture  of  the  Pregnant  Tube — Rupture  Be- 
tween the  Folds  of  the  Broad  Ligament — The  Growth  and  Development  of  the 
Fetus  to  Full  Term,  While  Still  Confined  Within  the  Tube — Interstitial  Pregnancy 
May  Terminate  by  Gradual  Growth  of  the  Fetus  Into  the  Uterine  Cavity — 
Tubo-Abdominal  Pregnancy — Secondary  Abdominal  Pregnancy — Tubo-Ovarian 
Pregnancy — Intraligamentary  Pregnancy — Ovario-Abdominal  Pregnancy — Abdom- 
inal Pregnancy  Secondary  to  Primary  Ovarian  Pregnancy — Resorption  and 
Tubal  Mole — Hematocele — Solitary  Hematocele — Infected  Hematocele — The  Ter- 
minal Changes — Bibliography. 

Tubal  pregnancy  may  primarily  eventuate  in  : 

i.  Early  death  of  the  ovum  with  complete  resorption  and  a  restora- 
tion of  the  tube  to  its  prepregnant  condition. 

2.  Death  of  the  embryo  with  the  formation  of  tubal  mole. 

3.  Tubal  abortion. 

4.  Rupture  of  the  pregnant  tube,  either  into  the  peritoneal  cavity  or 
between  the  folds  of  the  broad  ligament. 

5.  The  growth  and  development  of  the  embryo  may  proceed  to 
term,  when  either  the  fetus  dies  as  a  result  of  nutritional  failure, 
or  is  delivered  by  abdominal  section. 

6.  If  the  pregnancy  be  interstitial,  the  fetus  may  gradually  be  ex- 
truded into  the  uterine  cavity,  the  placenta  remaining  attached 
to  the  cornual  wall,  and  the  pregnancy  may  terminate  by  spon- 
taneous vaginal  delivery,  as  in  normal  intra-uterine  gestation,  the 
placenta  being  also  spontaneously  expelled. 

These  are  the  primary  terminations  of  tubal  pregnancy. 

Secondarily,  the  embryo  may  be  expelled  from  the  tube  and  the  pla- 
centa remain  behind,  the  pregnancy  going  to  term,  with  the  fetus  free 
m  the  abdominal  cavity  and  the  placenta  implanted  in  the  tube — the  so- 
called  tubo-ovarian  pregnancy.  Or,  the  entire  living  ovum  may  be  ex- 
pelled, the  placenta  reattaching  itself  to  any  tissue  within  the  peritoneal 
cavity  and  pregnancy  then  going  on  to  term — secondary  abdominal 
pregnancy.  In  either  of  these  instances  the  fetus,  unless  removed  by 
laparotomy,  dies,  and  proceeds  to  suppuration  and  necrosis,  lithopedion 
formation,   mummification,   or  adipocere.      Practically   speaking,   unless 

33 


34 


EXTRA-UTERINE  PREGNANCY 


terminated  by  surgical  intervention,  every  case  of  ectopic  pregnancy  re- 
sults fatally  for  the  child,  except  the  rare  case  of  secondary  uterine  ges- 
tation following  a  primary  interstitial  implantation  of  the  ovum. 
The  terminations  of  ovarian  pregnancy  are: 
i.  Rupture  into  the  peritoneal  cavity  with  hemorrhage  and  death 
of  the  fetus. 


Fig.  io. — A  Tubal  Mole.  All  gross  evidence  of  pregnancy  has  disappeared,  the 
distended  tube  being  filled  with  organized  clot.  On  microscopical  examination, 
distinct  placental   shadows   could  be   seen  in   the  tube  wall    (author's   case). 

2.  Rupture  of  the  sac  with  secondary  ovario-abdominal  pregnancy; 
the  placenta  remains  attached  to  the  ovarian  parenchyma. 

3.  Rupture  with  secondary  attachment  of  the  ovum — abdominal 
pregnancy  secondary  to  primary  ovarian  gestation. 

I.  Termination  by  Resorption  of  the  Ovum  takes  place,  in  the 
opinion  of  the  author,  much  more  frequently  than  is  commonly  be- 
lieved. In  taking  detailed  histories  of  gynecological  cases  when  some 
operation  is  contemplated  for  relief  of  pelvic  symptoms,  it  is  not  uncom- 
mon to  elicit  an  account  of  a  train  of  symptoms' strongly  suggestive  of  the 


THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY  35 

existence  of  an  ectopic  pregnancy  at  some  past  period  of  the  woman's 
life.  When,  upon  subsequent  laparotomy,  no  evidence  whatever  is  found 
of  any  lesion  of  the  tubes,  or  when  a  small,  nodular  area  of  fibrosis  exists 
in  one  tube,  the  fact  that  resorption  of  an  extra-uterine  embryo  has  at 
some  time  taken  place  is  at  least  suggestive. 

Furthermore,  the  finding  of  small,  absorbing  tubal  moles,  upon  the 
examination  of  certain  excised  tubes,  lends  additional  plausibility  to  this 
form  of  termination  of  extra-uterine  pregnancy.  Nothing  more  definite 
than  the  foregoing  facts  is  available,  but  it  seems  reasonable  in  the  face 
of  such  evidence  to  consider  death  and  resorption  of  the  ovum  as  one 
mode  of  termination  in  these  cases. 

2.  Death  of  the  Embryo  with  the  Formation  of  Tubal  Mole. — 
A  tubal  mole  results  when  the  fetus  dies  in  the  intact  tube,  with  marked 
hemorrhage  about  it  and  between  its  membranes.  At  the  same  time  the 
liquor  amnii  is  absorbed,  the  blood  more  or  less  organized,  and  a  struc- 
ture produced  which  is  identical  with  the  moles  occurring  in  uterine 
pregnancy.  Such  moles  may  vary  markedly  in  size,  according  to  the 
age  of  the  pregnancy  and  the  amount  of  hemorrhage,  and  may  be  re- 
tained in  the  tube  for  an  indefinite  period  (H.  A.  Kelly).  (Fig.  10, 
Fig.  11.) 

3.  Tubal  Abortion,  one  of  the  two  most  common  terminations 


Fig.  11. — A  Tubal  Mole,  the  Fetus  Still  Intact,  but  Undergoing  Degeneration. 
Tube  greatly  distended,  but  not  ruptured.  A  large  blood  clot  separates  the 
fetal  envelope  from  the  tube  wall. 


36 


EXTRA-UTERINE  PREGNANCY 


of  extra-uterine  pregnancy,  occurs  when  the  ovum  becomes  detached 
from  its  imbedding  site  in  the  tube  and  is  expelled  from  the  fimbriated 
extremity  of  the  tube  by  tubal  muscular  contraction,  the  abortion  being 
complete  when  the  ovum  and  its  envelopes  are  entirely  extruded  from  the 


Fig.  12. — Section  of  a  Tube  Showing  Incomplete  Tubal  Abortion.  The  embryo 
in  its  sac,  which  is  surrounded  by  a  large  clot,  is  seen  partially  extruded 
from  the  enormously  distended  fimbriated  extremity  (a).  The  uterine  end  of 
the  tube  is  shown  at  b   (case  of  Dr.  J.  M.  Baldy). 


Fig.   13. — A   Tube  Removed  a    Few   Hours   after   Complete   Tubal   Abortion   Had 
Taken  Place.     Note  the  enormously  hypertrophied  and  distended  fimbriae  at  a. 

tube  and  fall  into  the  abdominal  cavity,  and  incomplete  when  only  a 
portion  of  the  sac  protrudes  from  the  free  end  of  the  tube,  the  remainder 
being  still  confined  within  the  tube  walls.     (Fig.  12.) 

Tubal  abortion  is  usually  accompanied  by  severe  hemorrhage,  and 


THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY  37 

clinically  cannot  be  differentiated  from  rupture  of  the  tube,  although  oc- 
casional cases  are  recorded  where  the  hemorrhage  was  negligible  in 
amount.  The  possibility  of  this  termination  of  extra-uterine  pregnancy 
was  first  expressed  by  Werth  1  and  it  has  come  to  be  believed  that  this  is 
the  most  frequent  outcome  of  tubal  pregnancy  (Fig.  13).*  Opinions  as 
to  the  relative  frequency  of  abortion  and  tubal  rupture  vary  within  wide 
limits,  as  will  be  shown  later  in  discussing  this  phase  of  the  subject. 

According  to  Martin  2  this  termination  is  the  general  rule,  sponta- 
neous rupture  occurring  only  in  those  cases  in  which  occlusion  of  the  ab- 
dominal end  of  the  tube  precludes  the  possibility  of  an  abortion,  or  in 
which  the  ovum,  being  inserted  in  a  hernia  of  mucosa,  burrows  directly 
through  the  tube  wall. 

4.  Rupture  of  the  Pregnant  Tube. — (a)  Into  the  Peritoneal 
Cavity. — According  to  many  authorities  rupture  is  the  most  usual  mode 
of  termination  of  a  tubal  pregnancy.  Such  accident  happens  usually  be- 
fore the  twelfth  week,  most  commonly,  in  the  opinion  of  the  writer,  be- 
fore the  eighth  week  following  conception.  Naturally  ruptures  occur  in 
almost  a  direct  ratio  to  the  site  of  implantation  of  the  ovum.  Ampullar 
pregnancies  are  far  more  prone  to  end  by  tubal  abortion  than  by  rup- 
ture; midtube  pregnancies  terminate  almost  equally  by  these  two  acci- 
dents, while  in  isthmial  and  interstitial  pregnancies,  the  tube  usually  suf- 
fers a  rupture  of  its  wall.  The  tear  in  the  tube  is  commonly  over  the 
site  of  the  developing  placenta,  and,  when  intraperitoneal,  takes  place  on 
the  free  aspect  of  the  tube. 

The  older  writers  considered  this  accident  to  be  due  to  a  simple  over- 
distention  of  the  tube  wall  beyond  the  point  of  its  elastic  resistance.  Close 
study  of  the  pathology  led  to  a  change  in  thought,  and  it  was  held  that 
the  rupture  was  always  due  to  perforation  of  the  tube  wall  by  proliferat- 
ing syncytial  cells. 

My  own  view  is  that  a  combination  of  these  factors  brings  about  the 
lesion,  an  area  of  the  tube  wall  becoming  thinned  out  and  weakened  by  the 
erosive  action  of  the  syncytium,  and,  being  the  point  of  least  resistance, 
yielding  to  the  pressure  of  the  growing  ovum,  or  more  commonly  to  the 
accumulated  mass  of  blood  clot  gathering  in  and  about  the  oval  sac. 

Attention  has  been  called  to  the  divergent  views  held  as  to  the  rela- 
tive frequency  of  tubal  abortion  and  tubal  rupture.  In  1892  Schrenck 
found  only  six  cases  of  abortion  in  610  cases  of  tubal  pregnancy,  while 
the  reports  of  Martin,  Wormser,  Fehling,  Zletsch,  and  Mandle  and 
Schmidt  (quoted  by  J.  W.  Williams),  comprising  289  cases,  show  that 
78  per  cent  ended  by  abortion  and  only  22  per  cent  by  rupture.  Modern 
statistics  also  vary  very  greatly,  as  is  shown  by  the  following  table : 


38 


EXTRA-UTERINE  PREGNANCY 


No.  OF 

Tubal 

Other 

CASES 

Ruptures 

ABORTIONS 

TERMINATIONS 

1 06 

21 

55 

30 

117 

49 

64 

4 

59 

20 

25 

14 

76 

42 

20 

16 

309 

169 

81 

59 

Oastler,  q.  v . . 
Foskett,  q.  v. 
Williams,  q.  v 
Frank,  q.  v.  . 
Farrar,  q.  v . . 


To  glance  at  these  figures  is  to  be  convinced  that  the  relative  fre- 
quency of  these  two  terminations  of  tubal  pregnancy  has  by  no  means 
been  determined.  It  is  somewhat  difficult  to  reconcile  the  wide  differ- 
ence in  the  statistics,  all  made  by  expert  and  painstaking  observers,  with 
abundant  laboratory  facilities  for  the  verification  of  any  doubtful  speci- 
mens.   The  individual  experience  of  various  gynecologists  differs  greatly 


Fig.  14. — Rupture  of  a  Pregnant  Tube  Occurring  Subsequently  to  the  Develop- 
ment of  Tubal  Abortion.  At  a  is  seen  a  portion  of  the  clot  surrounding  the 
embryo,  being  extruded  from  the  fimbriated  extremity  of  the  tube,  while  at  b 
is  a  secondary  point  of  rupture,  which  was  bleeding  freely  at  operation  (author's 
case). 

in  this  respect,  and  until  very  large  groups  of  cases  are  collectively  studied, 
no  accurate  estimation  as  to  the  relative  frequency  of  tubal  abortion  and 
tubal  rupture  can  be  made. 

So  far  as  the  writer's  personal  observation  goes,  rupture  occurs  with 
nearly  double  the  frequency  of  tubal  abortion. 

Very  many  cases,  which  at  first  partake  of  the  nature  of  an  abortion, 
proceed  to  secondary  rupture  of  the  tube,  as  the  blood  accumulates  about 


THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY  39 

the  ovum  faster  than  the  propulsive  forces  of  the  contracting  tubal 
musculature  and  the  vis  a  tergo  of  the  blood  behind  the  ovum  can  act  to 
expel  the  latter  through  the  fimbriated  extremity;  and  rupture  finally 
occurs  by  reason  of  overdistention  of  the  tube,  especially  if  the  fimbriated 
end  be  occluded  by  old  inflammatory  processes  and  the  extrusion  of  the 
embryo  through  the  abdominal  ostium  is  thereby  impeded.    Fig.  14. 

Such  cases,  if  seen  early,  soon  after  the  development  of  symptoms,  and 
immediately  operated  upon,  will  be  listed  as  tubal  abortion,  whereas  in 
clinics  wherein  immediate  operation  is  not  practiced,  or  in  communities 
where,  by  reason  of  the  attitude  of  the  local  practitioners,  these  cases 
are  not  promptly  removed  to  hospitals,  time  is  given  for  secondary  rup- 
ture to  take  place  and  the  cases  are  accordingly  listed  as  tubal  ruptures. 
This  situation  will  serve  to  explain  the  variance  of  statistics  in  part,  but 
is  not  sufficient  to  entirely  reconcile  the  discrepancies  that  exist. 

The  amount  of  the  hemorrhage,  in  cases  of  rupture  of  the  tube,  is  in 
general  greater  than  where  tubal  abortion  has  taken  place,  and  varies 
with  the  location  of  the  rupture.  The  nearer  the  uterus,  the  more  severe 
the  hemorrhage,  is  the  rule.  Inasmuch  as  most  ruptures  occur  among 
isthmial  or  interstitial  pregnancies,  it  follows  that  bleeding  following  this 
accident  is  generally  profuse.  The  rupture  of  an  interstitial  pregnancy 
results  almost  always  in  excessive  bleeding,  sufficient  to  cause  a  fatal 
termination  in  most  instances,  unless  checked  by  immediate  surgical  in- 
terference. On  the  other  hand,  there  are  on  record  cases  of  tubal  rup- 
ture accompanied  by  but  slight  hemorrhage.  This  is  especially  true  where 
the  site  of  the  laceration  is  on  the  posterior  aspect  of  the  tube  at  its  mid- 
dle third,  where  the  blood  supply  is  limited  to  the  smaller  arterioles. 

(b)  Rupture  Between  the  Folds  of  the  Broad  Ligament. — In 
exceptional  cases  the  tube  may  rupture  along  its  inferior  aspect,  through 
the  mesosalpinx,  the  hemorrhage  thus  taking  place  in  the  extraperitoneal 
portion  of  the  tube,  and  dissecting  between  the  layers  of  the  broad  liga- 
ment. 

This  type  of  rupture  may  eventuate  in  the  death  of  the  embryo  and 
the  formation  of  a  broad  ligament  hematoma,  or  by  the  further  develop- 
ment of  the  embryo  as  a  secondary  broad  ligament  pregnancy  (exceed- 
ingly rare),  or,  if  the  tension  created  by  the  extravasated  blood  be  suf- 
ficiently great,  there  may  occur  a  secondary  rupture  of  the  broad  liga- 
ment, the  blood  eventually  escaping  into  the  peritoneal  cavity. 

This  variety  of  rupture  is  rarely  attended  by  severe  hemorrhage, 
and  from  the  clinical  standpoint  is  to  be  regarded  as  by  far  the  most 
favorable  type  with  regard  to  the  welfare  of  the  patient. 

When  the  growth  of  the  embryo  continues  after  its  escape  into  the 


40  EXTRA-UTERINE  PREGNANCY 

broad  ligament,  the  future  course  depends  largely  upon  the  degree  of 
completeness  with  which  the  placenta  has  been  separated  from  its  tubal 
attachment,  as  pointed  out  by  J.  W.  Williams,  who  states  that,  if  the 
placenta  remains  attached  to  the  tube  on  the  side  opposite  the  point  of 
rupture,  it  generally  becomes  displaced  upward  as  pregnancy  advances, 
and  comes  to  lie  above  the  fetus;  but  when  it  is  situated  near  the  point  of 
rupture,  it  gradually  extends  down  between  the  folds  of  the  broad  liga- 
ment, being  implanted  partly  upon  the  tube  and  partly  upon  the  pelvic 
connective  tissue. 

In  either  event  the  fetal  sac  lies  entirely  outside  the  peritoneal  cavity, 
and  as  it  increases  in  size,  the  peritoneum  is  gradually  dissected  up  from 
the  pelvic  walls.  This  condition  is  designated  as  extraperitoneal  or  broad 
ligament  pregnancy,  and  was  carefully  studied  by  Dezeimeris  3  in  1836. 

Lawson  Tait  laid  great  stress  upon  the  importance  of  broad  liga- 
ment rupture,  holding  that  only  such  cases  could  go  to  term ;  but  the  more 
careful  pathologic  work  of  later  investigators  has  proven  this  contention 
to  be  erroneous. 

Rupture  of  a  tubal  pregnancy  into  the  broad  ligament  is  uncommon. 
Williams,  quoting  the  gathered  statistics  of  Mandl  and  Schmidt,  Kiistner, 
and  Fehling,  finds  it  noted  in  but  4  out  of  276  cases,  and  out  of  50  speci- 
mens examined  by  Williams  this  lesion  had  taken  place  only  once.  In 
Frank's  study  of  80  cases  there  was  one  intraligamentous  rupture.  P.  F. 
Williams  found  3  broad  ligament  ruptures  in  132  cases,  while,  .strange  to 
say,  Foskett,  reporting  on  Coe's  cases,  noted  8  intraligamentary  ruptures 
out  of  49  cases,  a  most  unusually  high  percentage,  so  high  as  to  raise 
some  question  as  to  the  accuracy  of  the  interpretation  of  the  specimens. 

Rupture  of  the  tube,  either  into  the  peritoneal  cavity  or  between  the 
folds  of  the  broad  ligament,  generally  occurs  spontaneously,  but  it  may 
be  a  direct  result  of  trauma,  either  by  direct  or  indirect  violence.  Two 
such  cases  have  been  observed  by  the  writer.  In  one  of  them  a  woman 
was  kicked  in  the  abdomen  by  a  brutal  husband,  suffered  violent  pain 
and  at  once  went  into  collapse.  Diagnosis  of  some  hemorrhagic  form  of 
intraperitoneal  traumatism  was  made  and  immediate  laparotomy  per- 
formed, with  the  finding  of  a  ruptured  ampullar  pregnancy  of  about  6 
weeks'  duration,  which  had  not  previously  given  rise  to  symptoms. 

The  other  case  was  that  of  a  lady  who  had  suffered  some  slight  pelvic 
pain  for  several  days  and  who,  while  in  the  act  of  boarding  a  trolley  car, 
found  her  foot  slip  off  the  car  step,  with  a  sudden  contraction  of  the 
abdominal  muscles.  There  immediately  followed  a  tearing  pain  in  the  left 
side,  with  syncope  and  collapse.  She  was  admitted  to  Frankford  Hos- 
pital and  operated  upon  within  an  hour  of  the  accident.    A  ruptured  isth- 


THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY  41 

mial  pregnancy  of  the  left  tube,  probably  of  four  to  six  weeks'  duration, 
was  found,  the  abdomen  containing  a  large  amount  of  free  blood.  The 
tube  and  cornua  were  excised,  the  patient  making  an  uneventful  recovery. 
Vaginal  examination  has  resulted  in  the  rupture  of  an  ectopic  preg- 
nancy, and  this  fact  must  be  emphasized  in  order  to  avoid  the  error  of 
vigorous  bimanual  examination  in  suspected  cases.  Coitus  has  been  re- 
corded as  causing  such  accident. 

5.  The  Growth  and  Development  of  the  Fetus  to  Full  Term, 
While  Still  Confined  Within  the  Tube. — This  rare  and  interesting 
termination  of  tubal  pregnancy  is  occasionally  recorded  in  the  literature, 
though  the  writer  has  not  had  the  good  fortune  to  observe  a  case. 

Dr.  W.  P.  Conaway  4  reports  a  case  in  which,  on  opening  the  abdo- 
men, he  found  an  enormously  distended  right  tube,  which  was  very  ad- 
herent on  the  right  side  to  the  parietal  peritoneum  and  to  the  broad  liga- 
ment, but  perfectly  free  on  the  left  side.  There  were  no  adhesions  to  the 
omentum  or  mesentery.  The  uterus  was  slightly  enlarged  and  there  was 
a  marked  lateral  displacement  to  the  left  side.  The  left  tube  and  ovary 
were  apparently  normal.  The  right  ovary  was  enlarged,  cystic  and  easily 
removed  with  the  ovisac.  After  freeing  the  peritoneal  adhesions  the 
ovisac,  which  consisted  of  the  right  tube,  was  ligated  and  easily  re- 
moved. There  was  little  or  no  hemorrhage  and  no  evidence  of  previous 
hemorrhage.  This  ovisac  bore  the  same  relation  to  the  uterus,  ovary  and 
broad  ligament  as  a  hydrosalpinx.  The  contents  of  this  tube  were  a 
perfectly  formed  dead  fetus,  which  weighed  six  and  three  fourths  pounds, 
a  placenta  which  weighed  three  and  one-half  pounds,  and  about  two 
quarts  of  thick  slightly  greenish  fluid.  The  placenta  was  attached  to  the 
posterior  surface  of  the  sac,  and  between  the  layers  of  the  broad  ligament. 
The  placental  vessels  were  thrombosed.  The  ovisac  was  very  thin  and 
perfectly  intact,  until  easily  ruptured  in  freeing  the  adhesions.  The  ab- 
dominal cavity  was  flushed  with  normal  saline  solution,  drainage  inserted 
in  the  lower  part  of  the  wound,  and  the  incision  closed  with  through  and 
through  sutures  of  silkworm  gut. 

6.  Interstitial  Pregnancy  May  Terminate  by  the  Gradual 
Growth  of  the  Fetus  Into  the  Uterine  Cavity,  the  placenta  remain- 
ing attached  to  its  original  cornual  site,  its  growth  taking  place  toward 
the  uterus,  rather  than  too  greatly  distending  the  uterine  cornua.  Fetal 
growth  under  these  circumstances  may  continue  to  term,  though  this  is 
rarely  seen,  or  the  embryo  may  die  and  be  expelled  as  an  intra-uterine 
abortion. 

In  this  connection,  Webster  5  reports  a  case  wherein  the  patient  ex- 
pelled a  complete  uterine  decidual  cast,  to  which  was  attached,  at  one  of 


42  EXTRA-UTERINE  PREGNANCY 

the  upper  angles,  an  early  ovum,  which  had  evidently  been  situated  in  the 
interstitial  portion  of  one  of  the  tubes. 

Secondary  Terminations  of  Extra-uterine  Pregnancy 

In  addition  to  the  foregoing  primary  terminations  of  extra-uterine 
pregnancy,  certain  secondary  end  results  may  develop. 

Tubal  rupture  or  abortion,  but  far  more  commonly  the  former,  may 
be  succeeded  by : 

1.  Tubo-abdominal  pregnancy. 

2.  Secondary  abdominal  pregnancy. 

3.  Tubo-ovarian  pregnancy. 

4.  Intraligamentous  pregnancy. 

Ovarian  pregnancy  may  secondarily  result  in: 

5.  Ovario-abdominal  pregnancy. 

6.  Secondary  abdominal  pregnancy. 

1.  Tubo-Abdominal  Pregnancy  is  that  condition  which  is  found 
when,  following  a  rupture  of  the  tube  wall  on  its  free  surface,  the  pla- 
centa remains  attached  to  the  tube  wall  either  wholly  or  in  part,  fetal 
nutrition  in  the  latter  instance  being  derived  from  placental  adhesions  to 
contiguous  structures.  The  fetus  meanwhile  has  been  expelled  through 
the  aperture  in  the  tube  wall  and  lies  free  in  the  abdomen,  surrounded 
by  its  amniotic  envelope,  or  is  in  some  cases  entirely  devoid  of  covering. 

Whether  fetal  life  can  continue  or  not,  under  these  circumstances, 
depends  naturally  upon  the  traumatism  inflicted  upon  the  embryo  by  the 
act  of  tubal  rupture,  and  upon  the  area  of  placenta  remaining  imbedded 
in  the  tube  and  maintaining  unimpaired  vascular  connection  with  the 
tubal  vessels.  It  will  at  once  be  seen  that  the  possibilities  of  irreparable 
injury  to  the  embryo  from  hemorrhage,  as  well  as  the  tendency  to  com- 
plete or  nearly  complete  separation  of  the  immature  placenta  from  its 
abnormal  implantation  site,  are  so  great  that  the  proportion  of  tubo- 
abdominal  pregnancy,  in  which  development  of  the  fetus  continues  to 
term,  as  compared  with  immediate  fetal  death  following  rupture,  is  ex- 
tremely small.  Tubo-abdominal  pregnancy  is,  therefore,  a  rare  condition 
though  by  no  means  unique,  as  a  fairly  large  number  of  cases  are  re- 
corded. 

Webster  6  reported  a  case  in  which  the  child  lay  in  a  thin  walled  sac 
behind  the  omentum,  while  the  placenta  was  still  within  the  tube.  He 
designated  the  condition  as  tuboperitoneal  gestation,  and  supposed  that  it 
resulted  from  the  early  rupture  of  a  tubal  pregnancy,  with  the  escape  into 
the  peritoneal  cavity  of  the  fetus  surrounded  by  its  amnion,  and  that  the 


THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY  43 

latter  gradually  became  converted  into  the  wall  of  the  upper  portion  of 
the  sac. 

2.  Secondary  Abdominal  Pregnancy  is  that  condition  found 
when,  following  tubal  rupture  or  abortion  (more  commonly  the  latter), 
the  entire  ovum  is  expelled  into  the  general  peritoneal  cavity  and,  the 
embryo  continuing  to  live,  the  syncytia  attach  themselves  to  whatever 
tissue  they  may  and  reimbedding  takes  place  in  an  entirely  secondary 
location. 

This  possibility  is  denied  by  Williams,7  who  does  not  believe  that  the 
placenta  can  become  directly  attached  to  organs  far  removed  from  the 
pelvic  cavity,  such  as  the  stomach  and  diaphragm,  for  instance;  and 
when  such  conditions  are  observed,  Williams  thinks  that  one  has  to  deal 
with  a  broad  ligament  pregnancy,  in  which  the  placenta  is  situated  upon 
the  upper  portion  of  the  fetal  sac,  which  has  become  adherent  to  the  or- 
gan in  question. 

Certain  cases  are  recorded,  however,  which  seem  to  definitely  prove 
the  existence  of  true  secondary  abdominal  pregnancy,  as,  for  example, 
that  of  Lane,8  who  describes  a  case  of  pregnancy  at  term  at  which  abdo- 
minal section  was  begun  on  account  of  the  patient's  debilitated  condition. 
The  child  was  found  free  in  the  abdominal  cavity  and  lived  for  twenty- 
four  hours.  Profuse  hemorrhage  followed  delivery,  and  partial  detach- 
ment of  the  placenta  from  its  site  in  the  left  lumbar  fossa  anterior  to  the 
kidney  was  discovered.  The  uterus  was  apparently  normal,  save  for 
being  enlarged  to  the  size  of  a  ten  weeks'  pregnancy.  No  trace  of  rupture 
of  tube,  uterus  or  ovary  was  visible,  nor  was  there  any  connection  be- 
tween the  ovisac  and  the  uterus,  tubes  or  ovaries.  Lane  considers  this 
case  as  one  of  primary  abdominal  pregnancy,  but  it  is  moreTikely  that  it 
was  secondary  to  an  early  tubal  abortion. 

3.  Tubo-Ovarian  Pregnancy  occurs  when  the  fetal  sac  is  com- 
posed partly  of  tubal  and  partly  of  ovarian  tissue.  It  may  originate 
in  a  tubo-ovarian  cyst,  or  more  commonly  in  a  tube,  the  fimbriated  ex- 
tremity of  which  was  previously  adherent  to  the  ovary. 

Pathologically  these  cases  are  not  distinct  varieties,  but  begin  as  tubal 
or  possibly  rarely  as  ovarian,  pregnancies,  their  subsequent  course  being 
due  to  the  accidental  attachment  of  the  tubes  to  the  ovary.  A  specimen 
is  described  by  Paltauf  9  in  which  double  tubo-ovarian  cysts  communicated 
with  one  another.  Pregnancy  occurred  in  the  left  cyst,  and  at  autopsy 
a  sound  could  be  passed  from  the  left  cornu  of  the  uterus,  through  both 
ovarian  cysts,  and  back  into  the  uterine  cavity  through  the  right  tube. 

A  considerable  series  of  this  type  of  case  is  recorded  in  the  litera- 
ture. 


44  EXTRA-UTERINE  PREGNANCY 

4.  Intraligamentary  Pregnancy  results  when  the  tube  ruptures 
between  the  folds  of  the  broad  ligament  and,  the  placenta  remaining  fast 
to  its  tubal  attachment,  the  fetus  develops  within  the  broad  ligament. 
As  growth  proceeds  the  parietal  peritoneum  is  dissected  away  from  the 
tissues  and  the  entire  gestation  sac  continues  to  be  extraperitoneal.  The 
term  subperitoneopelvic  pregnancy  has  been  used  to  describe  this  variety, 
and  it  was  considered  a  common  occurrence  by  the  older  writers.  With 
more  careful  study  of  the  anatomy,  however,  intraligamentary  pregnancy 
has  been  found  to  be  quite  rare. 

5.  Ovario-Abdominal  Pregnancy. — Should  an  ovarian  pregnancy 
rupture  and  the  embryo  survive,  there  may  develop  an  ovario-abdominal 
pregnancy,  in  which  the  placenta  remains  attached  partly  to  the  ovary 
and  partly  to  the  contiguous  structures. 

The  case  reported  by  Norris,10  which  fulfilled  all  the  requirements  for 
a  justifiable  diagnosis,  presented  a  ruptured  ovarian  pregnancy,  with  the 
placenta  implanted  in  the  ovarian  substances  and  a  five  months,  mac- 
erated fetus  partially  within  the  gestation  sac  and  partially  in  the  ab- 
dominal cavity.  Norris  remarks  that,  in  studying  the  doubtful  cases  of 
ovarian  pregnancy  in  the  literature,  nearly  half  of  them  have  reached 
full  term.    He  thinks  that  many  lithopedions  are  ovarian  in  origin. 

6.  Abdominal  Pregnancy,  Secondary  to  Primary  Ovarian  Preg- 
nancy.— This  condition  is  theoretically  possible  and  differs  in  no 
way  from  abdominal  pregnancy  secondary  to  tubal  rupture,  save  in  the 
location  of  the  primary  embedding  site. 

The  End  Results  of  Extra-uterine  Pregnancy 

Untreated  or  long  standing  ectopic  gestation  may  eventuate  in : 

1.  Resorption  of  the  products  of  gestation, 

2.  Tubal  mole, 

3.  Hematocele,  which  may  be 

(a)  Diffuse, 

(b)  Solitary, 

(c)  May  become  infected. 

4.  When  fetal  development  continues  the  fetus  may  become: 

(a)  Lithopedion, 

(b)  Mummified, 

(c)  Adipocere, 

(d)  Skeletonized, 

(e)  May  suppurate. 

1  and  2.  Resorption  and  Tubal  Mole  have  been  discussed  in  the 
section  devoted  to  terminations  and  will  not  be  further  considered  here. 


THE  TERMINATIONS  OF  ECTOPIC  PREGNANCY  45 

3.  Hematocele. — The  older  works  on  gynecology  devote  much 
space  to  a  consideration  of  this  subject,  hematocele  being  considered  as  a 
distinct  clinical  entity.  Veit,  in  1884,  first  definitely  stated  the  connection 
between  hematocele  and  tubal  pregnancy,  but  the  great  exponent  of  this 
origin  was  Tait.11  This  author,  after  painstaking  investigation,  laid 
down  the  rule  that  the  presence  of  a  pelvic  hematocele  afforded  positive 
evidence  of  a  preexisting  extra-uterine  pregnancy. 

Tait's  view  has  been  proven  incorrect,  since  a  considerable  number  of 
cases  of  hemorrhage  in  the  pelvis  are  secondary  to  rupture  of  a  graafian 
follicle,  or  to  bleeding  into  the  ovarian  stroma  with  subsequent  rupture 
into  the  peritoneal  cavity,  without  any  evidence  of  pregnancy  whatso- 
ever. 

The  formation  of  a  hematocele  is  one  of  the  favorable  terminations 
of  ectopic  pregnancy,  in  that  the  development  of  organized  clot  predicates 
the  passage  of  sufficient  time  for  active  bleeding  to  have  ceased,  and  the 
danger  of  death  from  hemorrhage  to  have  passed.  Hematocele  is  the  re- 
sult, necessarily,  of  slow  hemorrhage,  and  it  follows  therefore  that  this 
termination  occurs  far  more  frequently  where  the  initial  lesion  is  tubal 
abortion,  with  its  trickling  of  blood  from  the  fimbriated  extremity  of  the 
tube,  rather  than  frank  rupture  of  the  tube  wall,  with  its  accompanying 
free  bleeding. 

The  presence  of  blood  in  the  peritoneal  cavity  sets  up  an  irritative 
plastic,  aseptic  peritonitis,  which  invites  adhesion  formation,  and  in  time 
the  entire  clot,  occupying  more  or  less  of  the  whole  pelvic  cavity,  becomes 
walled  off  by  intestinal  adhesions,  the  coils  being  firmly  glued  together 
and  serving  to  form  a  sort  of  capsule  for  the  clot.  It  has  been  held  that 
the  development  of  this  so-called  diffuse  hematocele  must  have  been  pre- 
ceded by  adhesions  between  the  pelvic  organs,  but  the  writer  inclines  to 
the  view  that  the  adhesions  slowly  form  as  a  reaction  of  peritoneal  sur- 
faces to  the  irritation  of  free  blood. 

(b)  Solitary  Hematocele  is  a  localized  collection  of  organized 
blood  clots,  usually  situated  in  close  proximity  to  the  fimbriated  end  of 
the  tube.  Its  histogenesis  is  satisfactorily  explained  by  Sanger,12  who 
describes  this  phenomenon  as  being  due  to  the  very  slow  oozing  of  blood 
from  the  fimbriated  end  of  a  tube  in  which  abortion  had  occurred,  the 
periphery  of  the  blood  clot  having  had  time  to  coagulate,  while  the  cen- 
ter is  steadily  being  increased  by  a  slow  accumulation  within  it.  The  ir- 
ritating quality  of  blood  on  peritoneum  causes  such  solitary  hematoceles 
to  be  shortly  surrounded  by  adhesions  binding  them  to  neighboring 
serous  structures. 

(c)  Infected  Hematocele. — Hematoceles,  from  their  very  nature, 


46  EXTRA-UTERINE  PREGNANCY 

are  excellent  culture  media  for  pyogenic  bacteria,  and  infection  of  these 
collections  is  a  frequent  and  dangerous  sequel.  The  colon  bacillus  is 
naturally  a  common  offender.  The  result  of  infection  by  this  or  other 
pyogenic  organisms  is  to  convert  the  hematocele  into  an  abscess,  which 
may  point  into  the  general  peritoneal  cavity,  with  subsequent  peritonitis, 
may  rupture  into  the  rectum  (a  very  fortunate  termination  for  the  pa- 
tient), or  into  the  bladder,  or  happily  may  sometimes  drain  into  the  va- 
gina. Infected  hematoceles  are  among  the  most  serious  and  dangerous 
sequelae  of  ectopic  pregnancy. 

4.  The  Terminal  Changes  which  may  offset  the  fetal  body, 
lithopedion,  etc.,  are  not  of  common  occurrence  and  play  but  a  small  role 
in  the  medical  history  of  ectopic  pregnancy.  Their  chief  interest  lies  in 
the  classification  and  the  genesis  of  their  formation,  discussion  of  which 
will  be  taken  up  in  detail  in  the  section  of  this  book  devoted  to  pathology. 

LITERATURE 

1.  Werth.     Beitrage  zur  Anatomic  und  zur  Operativen  Behandlung 

der  Extra-uterine  Schwangerschaft.    Stuttgart.     1887, 

2.  Martin,  A.    Zur  Kenntniss  der  Tubar  Schwangerschaft.  Monschr. 

f.  Gebh.  u.  Gyn.     1897.    5  :I>  244-    Quoted  by  Williams,  J.  W. 

3.  Dezeimeris,  J.  E.    Grossesses  Extra-uterines.    Jr.  de  Conn.  Med.- 

Chir.    Jan.,  1837.    Quoted  by  Williams,  J.  W. 

4.  Conaway,  W.  P.     Tr.  Phila.  Obst.  Soc.     1911-13. 

5.  Webster,  J.  C.    Extra-uterine  Pregnancy.     1895.    p.  76. 

6. Tubo-peritoneal   Ectopic   Gestation.      Edinburgh,      1892. 

p.  50.    Quoted  by  Williams,  J.  W. 

7.  Williams,  J.  W.  In  Kelly  and  Noble's  Gynecology  and  Abdominal 

Surgery.     Philadelphia,  1910.    p.  155. 

8.  Lane,  J.  W.    Bost.  Med.  Surg.  Jr.     1911.     164:683. 

9.  Paltauf.     Die  Schwangerschaft  in  Tubo-ovarialcysten.     Arch.  f. 

Gyn.     1887.     30:457.     Quoted  by  Williams,  J.  W. 

10.  Norris,  C.  C.     Primary  Ovarian  Pregnancy.     Surg.  Gyn.  Obst. 

1909.     9:123. 

11.  Tait,  L.    Lectures  on  Ectopic  Pregnancy  and  Pelvic  Hematocele. 

Birmingham,  1888. 

12.  Sanger,     tiber    Solitare    Hematocele    und    deren    Organization. 

Verhl.  d.  Deutsch.  Gesch.  f.  Gyn.     1893.    p.  281. 


CHAPTER  IV 

THE   ANATOMY   AND    PATHOLOGY    OF   EXTRA-UTERINE   PREGNANCY 

The  Mode  of  Implantation  of  the  Ovum  in  the  Tubes — Placentation  in  Tubal  Preg- 
nancy— Changes  in  the  Uterus  Produced  by  Ectopic  Pregnancy — The  Relation 
of  Uterine  Decidua  and  Decidual  Casts  to  Ectopic  Pregnancy — The  Cast  of  Mem- 
branous Dysmenorrhea — The  Pathology  of  Interstitial  or  Cornual  Pregnancy — 
The  Pathology  of  Ovarian  Pregnancy — Placentation — The  Pathology  of  Pelvic 
Hematocele — The  Pathology  of  Advanced  Ectopic  Pregnancy — Changes  in  the 
Tissues  the  Result  of  Ectopic  Pregnancy — Diagnosis  of  Ectopic  Pregnancy — 
The  Fate  of  the  Embryo  in  Ectopic  Pregnancy — Bibliography. 

A  review  of  the  normal  morphology  of  the  fallopian  tubes  will  natu- 
rally precede  a  discussion  of  the  implantation  of  the  fecundated  ovum  in 
their  walls.  These  structures,  embryologically  identical  with  the  uterine 
body,  being  the  upper  prolongation  of  the  mullerian  ducts,  are  situated  on 
the  upper  surface  of  the  broad  ligaments,  to  which  they  are  attached  by 
means  of  a  thin  fold  of  peritoneum,  the  mesosalpinx. 

The  tube  is  made  up  of  three  coats,  an  outer  serous,  an  inner  mucous 
with  two  layers  between  of  muscular  tissue,  one  in  which  the  fibers  are 
arranged  in  longitudinal  bundles,  externally,  and  one  with  its  fibers  dis^ 
posed  in  a  circular  direction,  encircling  the  lumen  of  the  tube,  internally 
The  mucous  membrane,  the  lining  of  the  tube,  is  covered  with  a  single 
layer  of  epithelium,  in  the  form  of  high,  columnar,  ciliated  cells,  which 
rest  upon  a  thin  basement  membrane.  There  is  no  submucosa,  the  epi- 
thelium being  separated  from  the  underlying  muscle  by  a  layer  of  con- 
nective tissue  of  varying  thickness,  this  arrangement  corresponding  with 
that  of  the  uterus.  The  mucosa  is  thrown  into  folds,  simple  at  the  uterine 
end  of  the  tube,  and  becoming  more  complex  as  the  fimbriated  end  is 
approached.  The  appearance  of  the  lumen  varies  according  to  the  portion 
of  the  tube  examined.  In  the  uterine  portion  four  elevations  are  seen, 
which  together  make  a  figure  resembling  a  Maltese  cross.  In  the  isthmial 
portion  of  the  tube  a  more  complicated  appearance  can  be  noted ;  while 
in  the  ampulla  the  lumen  is  almost  completely  occupied  by  the  arbores- 
cent mucosa,  which  upon  careful  examination  is  seen  to  be  made  up  of 
four  very  complicated,  tree-like  folds.     (Figs.  15- 16-17.) 

The  current  produced  by  the  cilia  of  the  tube  is  directed  toward  the 
uterus,  as  was  conclusively  demonstrated  by  the  experiments  of  Pinner, 

47 


48 


EXTRA-UTERINE  PREGNANCY 


Fig.  15. — Section  Through 
Uterine   Portion  of  Tube. 


Jani,  and  Lode,  who  showed  that  foreign  bodies  injected  into  the  abdomi- 
nal cavity  of  animals  made  their  way  into  the  tubes  and  were  gradually 
carried  down  into  the  uterus  and  thence  into  the  vagina.  (Description 
taken  from  J.  W.  Williams'  Obstetrics.) 

The  muscular  layers  of  the  tube  possess 
active  peristaltic  powers,  which  aid  in  the 
propulsion  of  the  ovum  towards  the  uterus, 
and  in  cases  of  tubal  abortion  or  tubal  preg- 
nancy act  to  force  the  ovisac  out  through  the 
fimbriated  extremity.  Developmental  errors 
are  common  in  the  fallopian  tubes.  Accessory 
ostia  and  congenital  diverticula  are  frequently 
noted  and,  as  has  been  said,  are  considered 
an  important  etiological  factor  in  the  pro- 
duction of  tubal  pregnancy. 

The  morphology  of  the  tubal  mucosa  ren- 
ders it  peculiarly  susceptible  to  invasion  and  serious  damage  by  infective 
processes.  When  the  infection  is  severe  and  acute,  with  pus  formation, 
the  epithelium  and,  indeed,  the  entire  mucosa  of  the  tube  may  be  destroyed 
and  the  fimbriated  extremity  closed.  In  this  stage  of  salpingitis  the  ovum 
cannot  enter  the  tube,  and  hence  tubal 
pregnancy  in  the  presence  of  pyosal- 
pingitis  is  almost  unknown.  When, 
however,  the  inflammation  is  limited  to 
the  endosalpinx  or  when  a  more  deep 
seated  infection  has  undergone  resolu- 
tion, there  results,  not  total  destruc- 
tion of  the  mucosa,  but  a  glueing  to- 
gether of  the  arborescent  folds,  with 
the  formation  of  false  diverticula  or 
canals  by  the  adhesion  of  the  ends  of 
the  regenerated  plicae.  Infection  of 
the  tube  usually  begins  at  the  mucosa 
and  progresses  from  within  outward, 
through  the  muscularis  and  serosa, 
to  invade  the  general  peritoneal  cavity. 

Such  infections  leave  in  their  train  areas  of  small  round  cell  infiltration 
and  a  fibrinous  exudate  scattered  throughout  the  tubal  musculature, 
and  these  areas  of  decreased  elasticity  play  an  important  part  in  pre- 
disposing to  tubal  rupture,  should  pregnancy  take  place  subsequent  to 
such  infective  process. 


Fig.  16. — Section  Through  Isthmic 
Portion  of  Tube. 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


49 


The  fibrinous  exudate  may  replace  all  of  the  muscular  elements  of  the 
tube,  in  which  event  no  further  peristalsis  would  be  possible.  So  pro- 
found a  destruction  of  the  muscle  is  exceedingly  rare  and  may  be  disre- 
garded clinically,  since  a  tube  so  damaged  is  not  apt  to  admit  an  ovum  into 
its  lumen.  Usually  in  a  healing  salpingitis  the  arborescent  longitudinal 
folds  of  mucosa  become  adherent  along  their  long  edges,  converting  the 
lumen  of  the  tube  into  one  of  many  channels  of  varying  length,  and  open 


Fig.  17. — Section  Through  Ampullar  Portion  of  Tube.     From  Williams. 


at  one  or  both  ends,  or  closed  sacs.  The  epithelium  contained  within  these 
postinflammatory  diverticula  is  in  places  destroyed,  but  quite  generally  is 
fairly  well  preserved  or  regenerated,  although  cilia  are  frequently  absent. 
It  is  in  such  canals,  open  at  the  distal  and  closed  at  the  mesial  end,  that  the 
fecund  ovum  becomes  obstructed  as  to  its  progress  toward  the  uterus, 
and  implants  itself  as  a  tubal  pregnancy.  It  will  be  seen  that  the  presence 
or  absence  of  cilia  is  of  but  little  importance  from  an  etiological  stand- 
point, if  the  foregoing  explanation  be  accepted.  Attention  has  been 
called  to  the  frequent  presence  of  diverticula  and  accessory  ostia  in  tubes, 
never  the  seat  of  inflammation,  and  therefore  congenital  in  their  nature. 


5o  EXTRA-UTERINE  PREGNANCY 

Such  writers  as  Huffman  lay  great  stress  upon  the  occurrence  of  such 
malformations  as  provocative  of  tubal  pregnancy,  and  many  cases  un- 
doubtedly result  from  this  cause.  As  a  general  proposition,  however,  the 
inflammatory  origin  seems  to  satisfactorily  account  for  the  bulk  of  the 
cases. 

True  mechanical  obstructions  of  the  ovum  by  kinks,  caused  by  ad- 
hesion bands  and  by  pressure  from  adjacent  neoplasms,  do  indubitably 
occur,  but  these  are  in  a  small  minority.  Tumors  within  the  tube,  polypi, 
etc.,  are  found  on  occasions,  but  are  accidental  causes  of  tubal  pregnancy 
only. 

The  theory  that  developmental  arrest  in  the  tube,  with  the  retention 
of  its  primitive  character  as  a  producer  of  decidua,  in  common  with  the 
uterus,  has  been  discussed  under  the  caption  of  causes  of  extra-uterine 

pregnancy.     It  is  a  most 

%s^  "^  attractive  theory,  but  not 

^'.Lv      i\  W<     satisfactory,     in     that     it 

.^\  JF  does  not  explam  tne  de- 

cidua found  in  abdominal 
>|        VHp     •    "!»§£*«  §     •'  pregnancies    of    the    true 

secondary  type,  nor  does 
j     it  explain  why  so  great  a 

majority  of  the  cases  of 
Fig    18  —  Tubal  Pregnancy  Caused  by  Diverticu- 

la  of  Fallopian  Tube.     From  Huffman.  tubal     pregnancy     present 

incontrovertible  evidences 
of  preexisting  inflammation  on  study  of  the  tubes.  Further,  there  are 
many  specimens  of  tubal  pregnancy  in  which  no  decidual  formation  can 
be  demonstrated,  and  in  many  more  the  decidua  is  so  indefinitely  formed 
as  to  be  practically  negligible.  Curiously  enough,  the  theory  of  mechani- 
cal or  postinflammatory  obstruction  to  the  progress  of  the  ovum,  as  a 
cause  for  tubal  pregnancy,  has  been  held  untenable  by  reason  of  a  piece 
of  experimental  work  performed  by  Mandl  and  Schmidt,1  who  ligated 
the  genital  tract  at  various  levels  in  rabbits  shortly  after  copulation.  They 
found  that  when  one  or  both  uterine  cornua  were  ligated,  ova  developed 
distal  to  the  constriction  produced  by  the  ligature.  When,  however,  the 
uterine  end  of  the  tube  was  ligated,  tubal  pregnancy  did  not  develop, 
though  they  record  the  finding  of  dead  ova  distal  to  the  tubal  ligatures. 
These  experiments  are  absolutely  valueless,  no  true  case  of  tubal  preg- 
nancy having  been  reported  in  the  lower  animals  to  my  knowledge,  save 
one  case  of  Waldeyer's  occurring  in  an  ape  and  therefore  not  to  be  con- 
sidered, since  the  uterus  and  tubes  of  the  higher  monkeys  conform  in  all 
respects  to  the  human  type  and  have  but  distant  resemblance  to  these 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


5i 


organs  in  the  lower  forms  possessing  the  bicornuate  uterus.  The  writer 
has  studied  every  specimen  of  female  genitalia  from  the  autopsies  held 
at  the  Philadelphia  Zoological  Garden  for  the  past  twelve  years  and  no 
case  of  tubal  pregnancy  has  been  noted.  Bland-Sutton  (quoted  by  Wil- 
liams) states  that  in  his  large  experience  in  the  Zoological  Gardens  of 
London  he  never  met  with  tubal  pregnancy  in  animals  and  does  not 
believe  it  to  occur. 

The  reason  is  a  very  simple  one.    The  uterine  tubes  in  those  orders 
of  mammalia  having  bicornuate  uteri  are  lined  with  a  mucosa  which, 


Fig.  19. — Cross   Section  of  Fallopian   Tube  of  the  Coati. 
(From  Wm.  Pepper  Laboratory  of  University  of  Pennsylvania.) 

while  it  is  thrown  into  folds,  is  exceedingly  simple  in  construction  as 
compared  with  that  of  the  human  female,  as  is  well  illustrated  by  Figs. 
19  and  20.  This  tubal  mucosa  does  not  hypertrophy  during  pregnancy 
among  the  lower  animals  and,  in  fine,  offers  a  very  poor  surface  for 
imbedding  of  the  ovum.  Furthermore,  the  tube  is  very  short  and  the 
writer  entertains  much  doubt  as  to  whether  fertilization  of  the  ovum 
takes  place  normally  in  the  tube  in  these  orders,  or  whether  it  does  not 
usually  occur  in  the  long  uterine  cornua. 

External  migration  of  the  ovum  has  been  advanced  as  a  cause  of  tubal 
gestation.  It  has  been  shown  that  the  ovum  given  off  by  one  ovary  may 
enter  the  tube  of  the  opposite  side. 

There  are  many  cases  recorded  in  which,  one  tube  and  the  opposite 
ovary  having  been  removed,  the  ovum  passes  across  the  peritoneal  cavity 


52 


EXTRA-UTERINE  PREGNANCY 


and  enters  the  remaining  tube.  Just  why  external  migration  should  be 
considered  as  a  cause  for  the  development  of  tubal  pregnancy  is  not  so 
clear.  Sippel 2  advanced  the  ingenious  hypothesis  that  the  ovum  occa- 
sionally became  impregnated  while  in  the  abdominal  cavity,  and  that  its 
transit  toward  the  opposite  tube  was  so'  delayed  that  it  attained  a  size  so 
great  as  to  preclude  its  passage  through  the  tube  to  the  uterus.  Inasmuch 
as  the  work  of  Peters  proved  that  no  chorionic  villi  are  present  until  the 
ovum  has  been  nourished  for  a  considerable  time  by  the  decidua  in  which 


^k 


mm 


>■ 

§     '   ■ 


4;     1 


ipgfcm1 


I'M- 


. 


Fig.  20. — Section  of  Fallopian  Tube  of  Cervus  Duvanceli,  Showing  Straight  and 

Simple  Rugae. 
(From  Wm.   Pepper  Laboratory  of  University  of  Pennsylvania.) 

it  is  embedded,  it  seems  far  more  likely  that  an  impregnated  ovum,  free  in 
the  peritoneal  cavity,  would  die  before  it  reached  the  tube. 

On  the  whole,  the  theory  of  external  migration  of  the  ovum  as  an 
etiological  factor  in  tubal  pregnancy,  is  difficult  to  reconcile  with  the 
known  facts. 

The  Mode  of  Implantation  of  the  Ovum  in  the  Tubes. — Study  of 
specimens  of  tubal  pregnancy,  based  on  the  epoch-making  work  of  von 
Spee  and  Peters  upon  the  uterine  implantations  of  the.  ovum,  demon- 
strates clearly  the  mechanism  of  this  process  in  the  tube.  Prior  to  the 
researches  of  von  Spee  and  Peters,  it  was  held  that,  wherever  an  ovum 
embedded  itself,  there  must  develop  a  decidua,  complete  in  its  three  divi- 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY       53 

sions  of  vera,  reflexa  and  serotina.  The  discovery  and  study  of  the 
Peters  ovum  disproved  this  theory  and  demonstrated  that  an  ovum  can 
develop  only  on  a  spot  free  from  epithelium,  sinking  through  the  de- 
cidua  to  rest  on  the  subepithelial  layer  of  the  muscularis,  and  producing 
by  its  presence  such  reaction  as  to  provoke  dilatation  of  the  lymph  spaces 
and  edema  of  the  myometrium  and  endometrium  immediately  surround- 
ing the  ovum.  A  decidua  is  not  necessary  for  the  imbedding  of  an  ovum, 
Peters'  specimen  also  showed  the  error  of  earlier  conceptions  with  regard 
to  the  decidua  reflexa.  Instead  of  being  an  upward  development  of  the 
vera,  the  reflexa  was  found  to  consist  merely  of  the  side  wall  of  the  cav- 
ity into  which  the  ovum  sinks,  the  upper  edges  of  the  side  walls  be- 
coming soon  united  over  the  ovum  by  organized  blood  clot  and  fibrin. 

With  regard  to  the  formation  of  decidua  in  the  tube,  while  it  un- 
doubtedly occurs,  there  are  cases  in  which  no  true  decidua  has  been  found, 
and  such  observers  as  Aschoff  3  and  Kuhne  4  greatly  doubt  the  very  ex- 
istence of  tubal  decidua.  Aschoff  found  no  decidua  at  the  placental  site 
in  tubal  pregnancy,  while  Kuhne  describes  only  a  pseudodecidua  con- 
sisting of  fibrin,  connective  tissue,  and  invading  ectoderm  cells.  Though 
slight  decidual  changes  may  occur  at  the  placental  area,  the  cells  which 
have  been  previously  described  as  decidual  are  considered  by  Kuhne  to 
be  the  cells  of  Langhans,  and  the  same  view  is  shared  by  Aschoff. 

The  place  of  meeting  of  spermatozoon  and  ovum,  long  the  subject  of 
spirited  debate,  has  been  definitely  learned  to  be  normally  situated  in  the 
tube  during  the  passage  of  the  ovum  through  that  channel  toward  the 
uterine  cavity.  It  has  been  shown  how,  by  inflammatory  changes  in  the 
tubal  mucosa,  by  the  presence  of  congenital  diverticula,  or  by  constriction 
from  external  pressure,  the  transit  of  the  fecundated  ovum  may  be  im- 
peded and  its  implantation  into  any  portion  of  the  tube  wall,  where  the 
arrest  of  its  progress  takes  place,  naturally  follows.  This  implantation 
may  occur  in  one  of  three  mechanisms,  the  columnar,  the  intercolumnar, 
or  the  centrifugal. 

With  regard  to  the  details  of  these  mechanisms,  Bandler  well  says 
that,  with  the  exception  of  the  absence  of  the  decidua  and  an  enveloping 
zone  composed  of  compacta,  the  processes  of  gestation  in  the  tube  are 
the  same  as  those  in  the  uterus,  modified  only,  as  would  naturally  be 
expected,  by  the  absence  of  the  decidua  and  the  thinness  of  the  tube  wall. 

Returning  to  the  mode  of  implantation,  columnar  imbedding,  which  is 
exceedingly  rare,  occurs  when  the  ovum  attaches  itself  to  one  of  the  tree- 
like folds  of  the  tubal  mucosa,  later  becoming  attached  to  other  folds  of 
the  mucosa,  but  nowhere  in  contact  with  the  tube  wall  itself.  The  ovum 
in  such  case  derives  its  nourishment  from  the  blood  vessels  of  the  mucosa 


54  EXTRA-UTERINE  PREGNANCY 

for  a  short  time,  but  presently  the  mucosa  is  eroded  by  the  phagocytic  ac- 
tion of  the  syncytial  cells  and  the  ovum  comes  to  lie  in  the  tube  wall,  the 
villi  of  the  chorion  penetrating  the  muscularis. 

Intercolumnar  implantation  occurs  when  primary  imbedding  takes 
place  in  a  cleft  between  the  folds  of  the  tubal  mucosa,  the  ovum  resting 
upon  the  surface  of  the  tube  wall,  at  once  burrowing  beneath  it  to  lie  in 
intimate  contact  with  the  musculature,  and  compressing  and  eroding  the 
neighboring  folds  of  mucosa.  In  such  case  the  surrounding  mucosal  folds 
unite  over  the  imbedded  ovum,  forming  a  sort  of  false  decidua  reflexa. 

The  centrifugal  form  of  implantation,  according  to  Bandler,5  occurs 
when  the  ovum  sinks  into  the  wall  of  the  tube,  and  an  invasion  of  the 
wall  and  vessels  by  the  villi  may  take  place,  even  up  to  the  serosa.  The 
capsularis  is  formed  by  muscularis  and  mucosa.  It  may  rupture  at  its 
summit.  The  invasion  of  the  vessels  entering  the  intervillous  space  may 
cause  hemorrhage.  The  villi  which  extend  up  to  the  serosa  may  cause 
bleeding,  though  their  penetration  is  so  gradual  that  these  points  are 
usually  covered  with  thrombi.  Finally,  a  rupture  may  take  place  at  the 
placental  site  through  multiple  perforations  producing  an  erosion.  Band- 
ler thinks  that  the  centrifugal  form  of  imbedding  furnishes  the  majority 
of  tubal  ruptures. 

No  matter  what  form  of  implantation  is  taken  by  the  tubal  ovum,  one 
factor  is  constant;  there  is  always  an  excessive  amount  of  hemorrhage 
about  the  ovum.  Otherwise,  provided  the  embryo  is  a  normal  one,  the 
attachment  of  the  ovum  to  the  tube  wall  is  closely  akin  to  that  seen  in 
normal  intra-uterine  implantation.  As  practically  no  true  decidua  is 
formed  in  the  tube,  there  is  always  present  about  the  ovum  an  excess  of 
blood,  since  it  is  thought  that  the  decidua  is  an  important  factor  in  pre- 
venting hemorrhage,  the  result  of  excessive  erosive  action  of  the  tropho- 
blast. 

According  to  Mall  the  blood  which  is  in  immediate  apposition  to  the 
trophoblast  does  not  coagulate  and  is  taken  up  by  the  syncytium,  which 
is  usually  very  markedly  vacuolated  and  serves  as  pabulum  for  the  ovum. 
The  trophoblast  also  has  a  marked  tendency  to  produce  a  peculiar  ne- 
crosis of  the  maternal  tissues  with  which  it  comes  in  contact,  producing 
the  so-called  fibrinoid  substance.  In  a  later  paper  Mall G  states  that  he  has 
never  found  any  tissues  that  could  be  considered  as  the  decidua,  nor 
has  he  found  any  specimens  of  early  implantations.  Whenever  he  en- 
countered an  ovum  which  was  very  small,  it  was  invariably  found  sepa- 
rated from  the  tubal  wall  by  a  definite  layer  of  blood. 

Berkeley  and  Bonney,7  in  a  careful  study,  define  the  formation  of 
decidua  in  tubal  pregnancy  in  three  ways.    The  term  decidua  may  be  used : 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  55 

1.  In  the  sense  of  a  definite  massive  proliferation  of  a  (supposed) 
subepithelial  stroma,  causing  a  decided  hypertrophy  of  the  tubal  mucous 
membrane,  analogous  to  that  occurring  in  the  uterine  mucosa.  Such  con- 
ditions as  described  by  Webster,  J.  W.  Williams,  and  others  were  not 
found  by  them. 

2.  In  the  sense  of  a  "decidua  capsularis"  separating  the  ovum  from 
the  tube  lumen,  just  as  the  decidua  reflexa  separates  the  intra-uterine 
ovum  from  the  cavity  of  the  uterus.  They  do  not  think  the  term  should 
be  used  in  this  sense. 

3.  In  the  sense  of  a  proliferative  reaction  of  the  connective  tissue 
cells  of  the  wall  of  the  tube,  irrespective  of  their  position.  The  term  de- 
cidua appears  to  be  used  by  most  modern  writers  in  this  sense. 

In  their  sections  the  absence  of  connective  tissue  reaction  to  the  in- 
vading trophoblast  is  one  of  the  most  striking  features.  Here  and  there 
are  patches  of  small  cells  with  single  rounded,  deeply  straining  nuclei, 
whilst  scattered  irregularly  about  in  the  muscle  tissue  are  certain  cells 
with  large  oval  vesicular  looking  nuclei,  which  stain  faintly  with  hema- 
toxylin. These  cells  are  decidua-like,  but  with  these  exceptions  the  ma- 
ternal tissue  appears  to  be  undergoing  a  passive  destruction.  (It  is 
probable  that  the  ovum  travels  toward  that  part  of  the  tube  where  the 
nutritional  vascular  supply  is  most  copious,  and  that  in  the  majority  of 
cases  it  is  primarily  implanted  in  the  attached  half  of  the  tube  wall.) 

The  gestation  sac  is  everywhere  bounded  by  a  layer  of  tissue  com- 
posed of  trophoblast  cells  and  masses  of  fibrin.  The  cells  of  the  tropho- 
blast present  two  main  forms,  the  large  mononuclear,  epitheloid  cell, 
and  the  multinuclear  masses  of  protoplasm  called  syncytia.  Of  these  the 
first  is  evidently,  the  primitive  one,  for,  in  addition  to  being  much  the 
more  numerous,  it  is  the  only  one  which  can  be  said  to  invade  the  mater- 
nal tissue.  These  trophoblast  cells  invade  the  tube  wall  by  insinuating 
themselves  between  the  muscle  tissue  in  several  strata,  but  always  tend- 
ing to  a  more  or  less  concentric  arrangement,  while  the  layers  of  ma- 
ternal tissue  in  contact  with  them  appear  to  be  undergoing  a  fibrinous 
degeneration  (the  fibrin  of  Nitabuch). 

Placentation  in  Tubal  Pregnancy. — The  tubal  and  the  uterine 
placenta  are  identical  in  formation,  with  the  difference  that,  as  develop- 
ment proceeds,  the  thin  tube  wall,  lacking  the  true  decidua  serotina,  is. 
easily  invaded  by  the  trophoblast  and  syncytial  cells,  since  there  is  no 
active  connective  tissue  reaction  set  up  in  the  tube  by  the  presence  of 
fetal  cells.  The  villi  rapidly  penetrate  the  tube  wall  and  are  soon  found 
just  beneath  the  serous  coat,  which  is  in  turn  invaded,  with  resulting 
rupture.     The  tubal  placenta  also  suffers  from  a  lack  of  nutrition,  the 


56 


EXTRA-UTERINE  PREGNANCY 


false  sinuses  formed  by  penetration  of  tubal  vessels  by  the  trophoblast 
being  in  no  sense  comparable  to  the  rich  blood  supply  developed  in  the 
uterine  wall.  This  is  a  probable  explanation  for  the  great  number  of 
pathological  embryos  found  in  extra-uterine  gestation.  Microscopically 
the  tubal  and  uterine  placentas  are  identical  in  all  respects.  An  interest- 
ing pathological  feature  in  this  connection  is  the  finding  of  masses  of 
syncytial  cells  or  even  bits  of  villi  in  the  veins  of  the  tube,  remote  from 
the  seat  of  the  pregnancy.  This  phenomenon  has  been  aptly  termed  de- 
portation by  Veit,8  who  explains  these  findings  by  the  fact  that  certain 
villi  are  not  firmly  attached  to  the  gestation  sac  and,  having  entered  a 
tubal  vein,  they  are  later  cut  off  from  their  attachment  to  the  ovum  and 
carried  by  the  blood  stream  to  varying  distances  from  this  point  of 
origin. 


Fig.  21. — Trophoblast  Cells  Between  Muscle  Bundles  of  Tube  Walls. 

In  addition  to  this  cause  of  isolated  masses  of  trophoblast  being 
found  in  the  tube,  there  is  the  inherited  tendency  of  these  cells  to  pene- 
trate tissue,  and  they  are  frequently  found  between  the  muscle  bundles  of 
the  tube  walls  (Fig.  21). 

From  the  foregoing  statements  it  will  be  seen  that,  so  far  as  is  now 
known,  the  implantation  of  an  ovum  in  the  tube  wall,  whatever  its 
mechanism,  very  shortly  results  in : 

First,  the  formation  of  a  gestation  sac  bounded  on  all  sides  by  a  layer 
of  trophoblastic  cells  and  masses  of  fibrin.  This  capsular  membrane  or 
pseudodecidua  is  formed  of  trophoblastic  elements  and  the  products  of 
degeneration  of  the  tubal  mucosa  overlying  the  ovum. 

Second,  the  trophoblastic  cells,  besides  forming  a  portion  of  the  sac 
wall,  lie  in  masses  between  the  muscular  fibers  of  the  tube  and  tend  to 
separate  muscle  bundle  from  muscle  bundle. 

Third,  there  is  rarely  formed  a  true  decidua,  in  the  sense  of  a  pro- 
liferation of  maternal  subepithelial  stroma  as  in  the  uterus. 

Fourth,  these  same  cells  directly  invade  the  walls  of  the  tubal  vessels, 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


57 


especially  near  the  site  of  implantation  of  the  ovum.  This  invasion  of 
vessel  walls,  according  to  Berkeley  and  Bonney,  occurs  either  directly 
from  without,  so  that  the  mass  of  trophoblast  replacing  the  vessel  wall 
is  directly  continuous  with  a  similar  mass  lying  outside  the  vessel,  or 
they  may  invade  the  vessels  along  the  line  of  the  perivascular  lymphatics. 
Fifth,  there  is  but  slight  connective  tissue  reaction  to  the  corrosion  of  the 
invading  trophoblast,  this  explaining  the  lack  of  resistance  of  the  tube 
wall  to  the  distention  of  the  growing  embryo. 

Sixth,  inasmuch  as  the  decidua  is  supposedly  an  important  factor  in 


' 


Fig.  22. — Rupture  of  a  Gestation  Sac  within  the  Tube  Lumen,  the  Well  Pre- 
served Embryo  Remaining  in  the  Center  of  an  Organizing  Blood  Clot.  A 
beginning  tubal  mole.     (Case  of  Dr.  H.  B.  Ingle.) 

inhibiting  the  excessive  corrosive  action  of  the  trophoblast  cells,  the  ab- 
sence of  true  decidua  in  the  tube  predicates  an  excess  of  blood  surround- 
ing the  ovum,  especially  since  the  intervillous  space  in  tubal  pregnancy  is 
always  markedly  vasculated  and  the  vessels  widely  invaded  by  the  masses 
of  trophoblast. 

The  foregoing  conditions  favor  early  rupture  of  the  gestation  saq. 
When  such  rupture  occurs,  it  may  be  followed  by  several  events. 

The  rupture  may  first  take  place  entirely  within  the  lumen  of  the 
tube,  the  embryo  be  destroyed  by  presence  of  blood  and  separation  of 
the  nutritive  villi  from  the  tubal  vessels  into  which  they  dip,  the  ovum 
subsequently  being  extruded  from  the  fimbriated  end  of  the  tube  by  the 
combined  vis  a  tergo  of  the  accumulated  blood  and  the  peristaltic  contrac- 


58  EXTRA-UTERINE  PREGNANCY 

tion  of  the  tube  walls,  the  whole  process  resulting  in  tubal  abortion. 

The  sac  may  rupture  and  the  blood  find  its  way  between  the  muscle 
fibers  of  the  tube  wall,  these  having  been  separated  by  masses  of  tro- 
phoblast,  as  has  been  seen.  Such  mechanism  results  in  a  hematoma 
of  the  tube,  and  may  be  compared  to  the  condition  that  results  when  a 
saccular  aneurism  becomes  diffuse.     (Fig.  22.) 

Whether  a  given  case  will  result  in  tubal  abortion  or  tubal  mole,  de- 
pends upon  the  completeness  with  which  the  sac  separates  from  its  tubal 
attachment  and  the  amount  of  the  hemorrhage,  together  with  the  degree 


Fig.  23. — Beginning  Rupture  of  an  Isthmial  Pregnancy  on  the  Inner,  Posterior 
Aspect  of  the  Tube.  The  rupture  is  shown  at  a,  a.  few  fronds  of  the  chorionic 
villi  having  been  forced  through  the  minute  opening   (author's  case). 

of  invasion  of  the  tubal  musculature  by  the  trophoblast  and  its  accord- 
ingly greater  or  less  contractile  power. 

The  gestation  sac  may  rupture  directly  through  the  tube  wall,  either 
along  its  free  edge  or  into  the  mesosalpinx  between  the  folds  of  the 
broad  ligament.  Whether  such  extratubal  rupture  takes  place  or  not, 
depends  upon  the  amount  of  erosion  of  the  tube  by  the  villi,  and  also  upon 
the  degree  of  degeneration  of  the  muscle  by  preexisting  inflammatory 
processes.     (Fig.  23.) 

The  mechanism  of  tubal  rupture  is  clearly  described  by  Miki  Kiutsi,9 
who  distinguishes  between  acute  tubal  rupture  and  the  chronic  form. 
Acute  tubal  rupture,  he  thinks,  is  due  to  compression  of  the  villous 
tufts,  accompanied  by  apoplexy,  ischemia,  destruction  of  the  coverings  of 
the  ovum,  hemorrhage  into  the  sac,  dilated  veins,  hematoma,  and  hemor- 
rhagic infiltration  of  the  edematous  connective  tissue.     The  primary 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  59 

cause  of  the  pressure  the  author  finds  to  be  a  plugging  of  the  large  inter- 
villous veins  which  carry  the  blood  to  the  villi.  The  supplying  arteries 
bring  this  blood  with  considerable  force  and  this  force  ruptures  the 
plugged  veins,  in  which  there  is  no  outlet  for  the  blood.  Later  the  cov- 
erings of  the  ovum  also  rupture.  Collateral  circulation  does  not  lessen 
the  pressure.  The  rupture  in  sudden  cases  does  not  show  a  smooth  open- 
ing, as  in  slow  cases,  but  an  irregular  rent.  The  strongest  compression  is 
seen  in  the  periphery  of  the  tufts.  Intracapsular  rupture  occurs  from 
bleeding  into  the  connective  tissue.  First  comes  pressure  from  sudden 
bleeding,  killing  the  ovum.  This  results  primarily  from  increased  ar- 
terial pressure,  secondarily  from  the  rapidity  of  the  blood  stream.  The 
death  of  the  ovum  comes  from  lack  of  nutrition,  due  to  obstruction  of 
the  chorionic  circulation;  it  is  a  secondary  result  of  the  intervillous 
pressure,  as  the  determining  causal  factor  of  the  rupture  of  the  chorionic 
villi,  which  have  a  loose  structure  with  large,  dilated  veins  and  large 
intervillous  spaces;  and  this  is  due  to  the  abnormal  implantation  of  the 
ovum.  Contributing  factors  may  be  contraction  or  torsion  of  the  tube, 
and  influences  from  without,  such  as  jumping,  lifting,  or  coitus.  Rup- 
ture of  the  tube  results  from  increased  venous  pressure  in  the  intervillous 
spaces,  and  this  from  pressure  on  the  veins  supplying  the  villi. 

Should  none  of  these  terminations  occur  early  in  pregnancy,  the 
embryo  continues  to  grow,  and  the  reason  why  most  tubal  pregnancies 
terminate  early,  while  a  few  go  on  to  term,  remains  one  of  the  unsolved 
problems  of  the  pathology  of  this  condition.  Suffice  it  to  say  that  some 
inherent  phylogenetic  action  in  certain  tubes  enables  them  to  resist  the 
erosive  action- of  the  villi,  and  to  accommodate  themselves  to  the  immense 
distention  of  the  growing  fetus.  Perhaps  the  factor  will  be  found  in 
some  primitive  reversion  of  the  tube  to  its  uterine  origin,  thus  permit- 
ting it  to  take  on,  to  some  extent,  the  morphology  of  the  uterine  cornu 
of  the  lower  mammals. 

In  the  advanced  cases,  the  structure  of  the  fetal  sac  is  closely  com- 
parable to  that  of  intra-uterine  pregnancy.  The  wall  of  the  tube  becomes 
analogous  to  the  uterine  body.  It  is  greatly  thinned  out,  the  muscular 
fibers  rapidly  undergo  a  metaplasia  into  connective  tissue,  though  they 
may  always  be  found  unchanged  in  greater  or  less  number.  This  varia- 
tion in  the  muscular  structures  of  the  pregnant  tube  may  bear  some  rela- 
tion to  the  reversion  changes  suggested  above.  The  muscular  elements 
sometimes  are  very  pronounced,  Pinard  10  reporting  a  case  in  which  the 
tubal  wall  was  so  dense,  and  its  contractions  so  pronounced,  as  to  make 
differentiation  between  it  and  the  uterine  body  difficult.  The  fetal 
membranes  and  the  placenta  may  develop  normally,  but  the  majority  of 


6o 


EXTRA-UTERINE  PREGNANCY 


extra-uterine  embryos  are  pathological,  as  will  be  shown  later.  The 
serous  surface  of  the  tube  becomes  thickened  by  hypertrophy  and  usually 
undergoes  some  inflammatory  change,  and  a  layer  of  fibrinous  exudate 
usually  forms  the  external  covering  of  the  tubal  gestation  sac. 

Advanced  tubal  pregnancy  may  terminate  in  rupture  at  any  time, 
with  or  without  embryonal  life  and  growth  continuing  outside  the  tube/ 
or  the  fetus  may  develop  to  maturity  within  the  tube  (vide  Conaway's 
case). 

Whether  a  given  tubal  pregnancy  will  terminate  by  rupture  or  by 


Fig.  24. — Late  Rupturing  Tubal  Pregnancy. 


tubal  abortion,  depends  on  a  series  of  considerations.  The  situation  of 
the  pregnancy  is  probably  the  most  certain  factor  in  determining  the 
mode  of  termination.  Both  by  reason  of  the  smaller  size  of  the  tube  as 
the  uterus  is  approached,  and  by  reason  of  the  longer  distance  to  be 
traversed  by  the  ruptured  ovum  to  the  fimbriated  extremity  of  the  tube, 
those  pregnancies  situated  in  the  uterine  half  of  the  tube  are  far  more 
prone  to  early  rupture  than  are  the  ampullar  ones.  The  degree  of  inva- 
sion and  degeneration  of  the  tubal  musculature  and  the  separation  of  its 
muscle  bundles  by  masses  of  trophoblast  as  well  as  the  penetration, 
through  the  muscle,  of  the  chorionic  villi,  also  are  active  factors  in  pro- 
ducing rupture  of  the  tube.  Further,  the  degree  of  patulousness  of  the 
abdominal  ostium  of  the  tube  has   an  important  bearing  on  the  ter- 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


61 


minatioiL  Should  the  fimbriae  be  glued  together  by  inflammatory  exu- 
date, the  abortion  of  the  ovum  will  be  retarded,  and  even  though  an 
abortion  has  begun,  the  accumulation  of  blood  behind  and  about  the  sac 
may  cause  a  secondary  rupture  of  the  tube  wall  before  the  obstruction 
at  the  occluded  fimbriated  end  is  overcome.  When  this  obstruction  is 
not  overcome,  and  the  force  of  the  hemorrhage  does  not  cause  sufficient 
pressure  to  rupture  the  tube,  the  dead  ovum,  surrounded  by  blood  clot, 


Fig.  25. — A  Gestation  Sac  with  Large  Surrounding  Blood  Clot  Found  Lying 
Free  in  the  Peritoneal  Cavity,  the  Result  of  a  Complete  and  Rapid  Tubal 
Abortion.    There  was  but  little  hemorrhage. 


remains  in  situ-  to  become  organized,  partially  absorbed  and  result  in  a 
tubal  mole. 

Obviously,  none  of  these  terminations  can  be  forecasted. 

If  the  abortion  be  complete  and  rapid,  hemorrhage  is  usually  small 
in  amount,  since  the  empty  tube  may  in  a  measure  contract,  and  the 
blood  spaces  be  sufficiently  occluded  to  prevent  free  hemorrhage  and  per- 
mit clotting.  When  hemorrhage  from  the  tube  does  continue  under  these 
conditions,  it  is  due  to  the  fact  that  contractions  of  the  tubal  muscle  are 
feeble  and  ineffectual,  and  also  that  true  decidua,  with  its  inhibiting  effect 
upon  bleeding,  is  absent.  On  the  other  hand,  when  the  dead  ovum  is 
partially  extruded  from  the  abdominal  end  of  the  tube,  the  latter,  being 


62  EXTRA-UTERINE  PREGNANCY 

still  distended  by  the  ovum,  cannot  contract,  and  the  open  blood  spaces 
continue  to  pour  out  blood,  which  accumulates  in  the  tube  behind  the 
ovum  until  sufficient  pressure  is  reached  to  force  it  out  between  the  tube 
wall  and  the  sac,  when  the  pressure  is  reduced,  the  process  repeating  it- 
self indefinitely.  It  is  this  type  of  slow  but  continuing  hemorrhage  that 
so  frequently  results  in  hematocele  formation,  the  blood  lying  in  Douglas' 
pouch  having  ample  opportunity  to  clot  firmly  and  the  clot  being  stead- 
ily augmented  by  fresh  accretions  of  blood. 

Changes  in  the  Uterus  Produced  by  Ectopic  Pregnancy. — The 
influence  of  an  impregnated  and  imbedded  ovum,  wherever  situated,  al- 
ways brings  about  an  evolution  of  the  uterus  to  some  degree,  together 
with  the  development  of  a  decidua  vera  in  that  organ.  This  invariable 
reaction  has  been  denied  by  certain  observers,  but  no  definite  case  appears 
to  be  recorded  in  the  literature,  and  inasmuch  as  the  decidua  is  not  un- 
commonly expelled  from  the  uterine  cavity  previous  to  a  case  of  tubal 
pregnancy  coming  to  operation,  the  absence  of  this  tissue  on  examination 
of  the  excised  uterus  offers  no  proof  that  it  has  not  been  so  expelled. 

The  uterus,  while  always  enlarged  in  ectopic  gestation,  rarely  reaches 
the  same  dimensions  it  would  if  the  pregnancy  were  intra-uterine  and  of 
the  same  age,  the  stimulus  being  less  pronounced.  The  increase  in  size 
of  the  uterus,  according  to  Sampson,11  is  due  to  two  evident  factors, 
hyperemia  and  a  thickening  of  the  endometrium.  Possibly  the  muscle 
fibers  are  also  increased  in  size.  The  changes  in  the  endometrium  are 
quite  similar  to  those  found  in  the  decidua  vera  of  early  uterine  preg- 
nancy and  also  vary  with  the  age  of  the  pregnancy. 

Upon  the  death  of  the  ovum  and  the  termination  of  the  ectopic  preg- 
nancy, whatever  may  be  the  variety  of  this  process,  the  uterus  always 
undergoes  involution. 

While  the  tubal  pregnancy  is  being  terminated,  the  tube  undergoes 
a  measure  of  intermittent  contraction,  endeavoring  to  expell  its  con- 
tents. These  contractions  are  transmitted  to  the  uterus,  which  in  time 
contracts  as  in  labor,  or  better,  abortion,  but  in  far  less  marked  degree. 

The  clinical  expression  of  such  uterine  contractions  is  bleeding  from 
the  endometrium,  with  the  extrusion  of  portions  of  decidua.  It  may  be 
concluded,  therefore,  that  uterine  bleeding  and  the  passage  of  decidua 
in  the  presence  of  extra-uterine  gestation  invariably  predicates  hemor- 
rhage about  the  aberrant  ovum  and  the  termination  of  the  ectopic  preg- 
nancy. So  long  as  the  embryo  is  living  and  development  is  in  progress, 
there  is  no  uterine  bleeding.  The  reason  that  uterine  bleeding  may 
continue  for  a  considerable  time  after  the  attack  of  pelvic  pain  which 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  63 

apparently  marks  the  destruction  of  the  embryo,  lies  in  the  fact 
that  the  termination  of  the  tubal  pregnancy  is  not  necessarily  at  once 
complete,  chorionic  villi  remaining  alive  and  exerting  their  stimulus 
upon  the  uterus. 

In  a  series  of  cases  wherein  Sampson  removed  the  uterus  in  the 
course  of  operation  for  extra-uterine  pregnancy  and  subjected  these 
uteri  to  close  study  by  injection  of  their  blood  vessels,  he  found  "that  the 
uterine  bleeding  in  all  cases  was  of  venous  origin  and  arose  from  the 
endometrium,  and  in  not  a  single  instance  did  it  escape  from  the  tube 
into  the  uterine  cavity." 

Sampson  further  states  that  "following  the  complete  termination  of 
the  tubal  pregnancy,  uterine  involution  takes  place,  which  differs  only  in 
degree  from  that  following  uterine  pregnancy.  The  uterus  becomes 
smaller,  due  to  decreased  arterial  and  venous  hyperemia  and  atrophy  of 
the  endometrium."  This  uterine  involution  is  divided  into  two  stages, 
a  regressive  and  a  reparative,  the  former  being  marked  by  an  atrophied 
endometrium,  the  compact  layer  absent  or  thin,  the  arterioles  few  and 
difficult  to  detect  and  the  venous  spaces  dilated. 

In  the  reparative  stage,  the  endometrium  becomes  thicker,  its  sur- 
face is  thrown  into  folds,  and  there  is  a  formation  of  a  compact  layer 
and  glandular  hyperplasia.  Sampson  holds  "that  where  the  process  of 
involution  is  delayed  by  the  influence  of  an  incomplete  termination  of  the 
tubal  pregnancy,  a  condition  arises  apparently  analogous  to  subinvolution 
of  the  uterus,  due  to  retention  of  some  of  the  products  of  uterine  concept 
tion.  As  these  cases  are  operated  upon  after  the  onset  of  the  termina- 
tion of  the  pregnancy,  the  uterus  has  already  been  influenced  by  three 
factors  or  forces:  the  first  of  these  is  pregnancy;  the  second  is  labor; 
and  thirdly,  with  the  onset  of  the  termination  of  the  pregnancy,  i.e.,  labor, 
the  involution  of  the  uterus  begins.  The  stimuli  exerted  on  the  uterus 
by  pregnancy  and  involution  are  therefore  antagonistic." 

These  changes  in  uterine  blood  supply  are  well  shown  by  the  Figures 
taken  from  Sampson.     (Figs.  26,  27,  28.) 

The  Relation  of  Uterine  Decidua  and  Decidual  Casts  to  Ectopic 
Pregnancy. — It  has  been  shown  above  that  uterine  bleeding  in  the 
presence  of  ectopic  gestation  follows  the  termination  of  the  tubal  preg- 
nancy, and  is  literally  an  expression  of  sympathetic  labor  on  the  part  of 
the  uterus.  Following  the  bleeding  there  is  usually  expelled  from  this 
organ  either  portions  of  its  thickened  endometrium,  or  the  entire  uterine 
decidua  vera  is  separated  en  masse  in  the  form  of  a  decidual  cast.  Such 
casts  are  passed  in  nearly  one  half  of  the  recorded  cases  of  tubal  preg- 
nancy which  have  been  subjected  to  close  study. 


64 


EXTRA-UTERINE  PREGNANCY 


In  a  considerable  number  of  cases,  where  the  first  attack  of  pain  and 
the  termination  of  the  pregnancy  have  taken  place  some  time  before  opera- 
tion, the  decidua  may  have  been  entirely  exfoliated  and  replaced  by  a 
normal  uterine  mucosa.  Curettage  and  examination  of  the  endometrium, 
after  such  an  event  would  naturally  lead  to  negative  findings  and  the 


Fig.  26. — Uterine   Changes    Consequent  on   E*  topic    Pregnancy.    From    Sampson. 

conclusion  that  uterine  decidua   is   not  necessarily  present   in  ectopic 
pregnancy. 

From  a  close  examination  of  the  literature  and  of  his  own  cases, 
the  writer  is  convinced  that  in  every  instance  where  a  fecundated  ovum 
has  imbedded  and  developed,  no  matter  to  what  extent,  a  uterine  decidua 
is  formed,  completely  or  not,  according  to  the  extent  of  development  of 


- 


Fig.  27. — Uterine   Changes   Consequent   on   Ectopic   Pregnancy.    From    Sampson. 


the  ovum.  The  uterine  decidua  is  in  the  main  identical  with  that  of 
normal  intra-uterine  pregnancy,  although  there  may  be  some  variation 
in  the  relative  thickness  and  density  of  the  several  layers. 

The  passage  of  a  decidual  cast  has  been  considered  as  important  in 
the  diagnosis  of  extra-uterine  pregnancy.  This  is  true,  but  it  must 
be    remembered    that    such    casts    are    simply ,  significant    of    preg- 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


65 


nancy  in.  some  form,  and  may  well  be  found  in  connection  with  the 
early  abortion  of  an  intra-uterine  ovum.  Only  when  a  cast  is  passed, 
which  microscopically  presents  the  characteristic  of  decidua,  i.e.,  a  dis- 
tinct division  into  a  stratum  compactum  and  a  stratum  spongiosum,  and 
which  fails  to  exhibit  any  evidences  of  chorionic  villi,  can  a  reasonable 
diagnosis  of  the  existence  of  ectopic  pregnancy  be  made  from  this 
evidence  alone.  In  addition,  allowances  must  be  made  for  the  altera- 
tion in  the  structure  of  the  decidua  brought  about  by  hemorrhage  into 
its  substance,,  decomposition  changes,  etc. 


%; 


Fig.  28. — Uterine  Changes   Consequent  on   Ectopic    Pregnancy.    From    Sampson. 

An  interesting  example  of  the  possible  diagnostic  error  from  an 
examination  of  decidual  casts  is  that  reported  by  Frank.12  A  woman 
of  27  had  had  amenorrhea  for  two  months  and  believed  herself  preg- 
nant (nausea,  increase  in  size  of  the  breasts).  For  two  weeks  she  had 
bled  slightly  and  on  one  occasion  bled  rather  profusely  and  fainted. 
On  examination  there  was  a  moderate  amount  of  dark  bloody  flow,  no 
clots.  The  uterus  was  slightly  enlarged,  no  distinct  Hegar's  sign  could 
be  obtained,  and  the  right  adnexa  were  tender  and  appeared  slightly  en- 
larged. The  symptoms  continued  for  the  next  two  days  and  on  the 
third  day  the  patient  passed  a  typical  triangular  uterine  cast,  complete 
except  for  its  extreme  fundal  portion.  Immediate  microscopical  exami- 
nation showed  only  a  fully  developed  decidua,  with  absence  of  villi.  On 
these  findings  a  diagnosis  of  tubal  gestation  was  made.  Twenty-four 
hours  later  the  woman  passed  a  smaller  elliptical  mass,  which  proved  to 


66 


EXTRA-UTERINE  PREGNANCY 


be  a  small  degenerated  ovum,  surrounded  by  organized  blood.     The  pa- 
tient recovered  without  operation. 

Frank  believes  that  at  the  onset  of  symptoms  the  ovum  had  become 
separated  from  the  decidua  by  slow  and  progressive  hemorrhage.  The 
blood  had  completely  enclosed  the  ovum.  Then,  later,  further  bleeding 
had  detached  the  decidua,  which  was  expelled  first,  and  lastly  the  ovum 
was  extruded.  As  a  rule  it  is  to  be  expected,  in  such  cases,  that  at 
least  a  few  villi  should  adhere  to  the  decidua,  so  that,  in  spite  of  this 
most  unusual  occurrence,  vital  importance  should  be  attached  to  de- 


Fig.   29. — Decidua    of   Uterus    in    Case   of    Tubal    Pregnancy.    From  Frank. 


cidual  casts  in  patients  suspected  to  be  suffering  from  ectopic  preg- 
nancy.    (Fig.  29.) 

An  excellent  description  of  the  appearance  and  structure  of  decidual 
casts,  as  well  as  of  those  of  membranous  dysmenorrhea,  which  are  some- 
times confused  with  them,  is  contributed  by  Huffman  13  and  is  here  re- 
produced in  detail. 

''The  Decidual  Cast  of  Ectopic  Pregnancy. — The  size  of  the 
decidual  cast  depends  upon  the  duration  of  the  pregnancy  at  the  time 
it  is  cast  off.  It  is  usually  somewhat  fleshy,  being  several  millimeters 
in  thickness,  and  is  of  a  pink  color.  If  it  is  complete  and  its  separation 
has  been  unaccompanied  by  hemorrhage,  it  forms  a  little  sac,  which  may 
be  slipped  over  the  little  finger.  The  inner  surface  is  smooth  and  glis- 
tening. The  outer  surface  is  rough  or  shaggy  and  numerous  shreds  of 
blood  clot  are  found  scattered  over  it.    In  some  cases,  especially  when  the 


,    PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  67 

rupture  of  the  ectopic  growth  has  caused  severe  anemia,  the  cast  presents 
a  very  striking  pale,  pinkish,  mottled  appearance.  In  cases  of  advanced 
gestation,  that  is  of  two  or  three  months'  duration,  the  cast  may  be 
eight  by  four  centimeters.  If  the  separation  has  occurred  slowly  and 
has  been  attended  by  hemorrhage,  the  cast  may  be  very  thick  and  bulky 
from  the  addition  of  blood  clot.  The  microscopical  appearances  are 
those  of  decidua  vera,  the  same  as  in  normal  pregnancy,  being  composed 
mostly  of  the  compact  layer  and  partly  of  the  spongy  layer.  If  hemor- 
rhage has  occurred  into  the  decidua,  if  necrosis  has  supervened,  or  if 
leukocytic  infiltration  has  taken  place,  the  decidua  will  have  been  altered 
accordingly.  These  possibilities,  as  well  as  the  postmortem  changes,  will 
occur  during  the  exit  from  the  uterus  and  the  sojourn  in  the  vagina,  and 
are  so  variable  that  no  two  casts  have  exactly  the  same  appearance,  al- 
though, of  course,  the  essential  histological  details  are  there.  (Fig.  30.) 
"The  Cast  of  Membranous  Dysmenorrhea. — The  size  of  menstrual 
casts,  when  entire,  is  never  more  than  four  centimeters  by  two  and  a 
half.  The  membrane  is  not  so  thick  as  decidua  and  is  much  more  fra- 
gile. It  cannot  be  handled  in  the  same  manner  as  a  decidual  cast  and  it 
does  not  have  a  cavity  large  enough  to  insert  the  finger.  As  a  back- 
ground for  the  microscopical  appearances,  one  should  have  in  mind  the 
appearance  of  the  premenstrual  endometrium,  with  its  elongated  and 
tortuous  glands  and  its  swollen  stroma  cells.  One  sees  that  an  excessive 
exudation  of  leukocytes  has  occurred,  together  with  the  formation  of 
more  or  less  fibrin.  This  process  may  have  been  so  extensive  and  severe 
as  to  have  caused  the  death  of  the  involved  mucosa,  and  it  will  be  only 
here  and  there  that  the  remains  of  an  utricular  gland  or  area  of  unaf- 
fected stroma  may  be  seen.  Here  too  one  must  consider  the  changes 
induced  during  the  time  of  expulsion.  Between  the  changes  induced 
in  the  glands  of  the  endometrium  during  the  premenstrual  period  and  the 
changes  induced  during  pregnancy  there  is  no  distinct  difference,  except 
in  size,  and  this  is  not  sufficient  in  degree  early  in  the  course  of  pregnancy 
to  be  of  any  aid  to  diagnosis.  We  have,  therefore,  to  resort  to  the  recogni- 
tion of  the  changes  inducted  in  the  stroma  cells,  which  in  pregnancy 
undergo  a  distinctive  change,  becoming  very  large  with  translucent 
cytoplasm  and  very  dense  nuclei.  These  cells,  the  so-called  decidua  cells, 
which  form  the  decidua  compacta,  are  so  very  characteristic  that  they  are 
proof  of  pregnancy.  When  accurately  compared  with  the  so-called 
decidual  reacting  cell  of  menstruation,  they  are  found  to  be  very  much 
larger,  besides  presenting  dense,  well  defined  nuclei  and  being  packed 
closely  together.  The  stroma  cells  of  menstruation  are  much  smaller, 
have  pyknotic  nuclei,  and  are  not  firmly  packed  together,  except  in  small 


i 


#?^^ 


^ 


*  55 


I 


asfc^w 


-•H„ 


ft 


v^ 


Vs^^Se 


g^« 


Fig.  30. — Microscopic  Section  of  Decidual  Cast.    From  Huffman. 


68 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  69 

groups,  the  lymph  spaces  preventing  this  by  being  engorged.  (Fig.  31.) 
"To  resume  then,  we  may  say  that  the  decidua  compacta  is  the  real 
criterion  for  determining  pregnancy  by  an  examination  of  casts.  A 
decidual  cast  indicates  pregnancy,  not  always  ectopic  pregnancy,  be- 
cause decidual  casts  may  be  passed  from  the  non-gravid  horn  of  a 
double  uterus  during  pregnancy.    We  must  keep  in  mind  also  the  possi- 


jj^a^K^^ 

ffi®£$$  T-;y  ?■  T;;t^fv  <^ . 

i-„'-r*±-*\"..'y ^~  '.'■_ 

1 

f"~  '*»/> ..•_?',<.v     ■ 

-■•'    • 

* 

•-**•";•• »-  '»  «-"*'''•  ' 

'  /**,"-.'-  *'.    j*»*'.' 

. 

i     .    ;  "  ;- : 

Fig.   31. — Decidua    Cells.    From   Huffman. 

bility  of  cases  like  those  of  Dakin  and  Griffith,  where  decidual  casts  were 
passed  without  finding  any  absolute  evidence  of  ectopic  pregnancy  when 
operated  upon  later.  In  Dakin's  case  a  peculiar  layer  of  epithelial  cells 
was  found  near  the  corpus  luteum  cyst,  that  were  regarded  by  Dr. 
Rolleston  as  relics  of  the  wolffian  body.  In  Griffith's  case  there 
was  no  conclusive  evidence  of  ectopic  pregnancy,  and  he  suggests 
that  an  impregnated  ovum  probably  initiated  the  process  and  then 
died." 

The  Pathology  of  Interstitial  or  Cornual  Pregnancy. — Intersti- 
tial pregnancy  is  the  rarest  form  of  ectopic  gestation,  with  the  exception 


70  EXTRA-UTERINE  PREGNANCY 

of  ovarian,  although  modern  literature  contains  the  record  of  a  fair  num- 
ber of  cases.  The  relative  frequency  of  this  variety  of  extra-uterine  ges- 
tation, according  to  Wynne,14  who  studied  the  literature  on  this  sub- 
ject, is  1.16  per  cent,  eighteen  cases  of  interstitial  pregnancy  being 
recorded  among  a  total  of  1547  cases  of  ectopic  pregnancy  studied.  In 
the  records  of  the  Johns  Hopkins  Hospital  there  were  two  such  cases 
among  304  of  extra-uterine  gestation.      (See  Frequency,  Chapter  II.) 

The  etiology  of  interstitial  pregnancy  is  practically  that  of  ectopic 
gestation  generally,  inflammatory  lesions  of  the  tube  in  its  interstitial 
portion  being  probably  the  most  common  cause.  It  has  long  been  thought 
by -the  writer  that,  since  the  differentiation  of  the  miillerian  duct  into 
uterus  and  tube  begins  at  the  uterine  cornu,  this  area  would  naturally  be 
more  apt  to  present  some  arrest  of  development,  the  uterine  morphology 
continuing  for  some  little  distance  into  the  tube.  Such  reversionary  struc- 
ture would  predispose  to  embryonal  imbedding  in  this  location. 

Interstitial  pregnancy  has  been  divided  according  to  the  location  of 
the  imbedding  site  into  three  groups  (Klebs)  : 

1.  Utero-interstitial  pregnancy,  when  the  ovum  occupies  the  uterine 
end  of  the  cornual  canal. 

2.  Tubo-interstitial  pregnancy,  when  the  ovum  occupies  the  tubal  end 
of  the  cornual  canal. 

3.  Interstitial  pregnancy  proper,  when  the  ovum  is  imbedded  about 
the  middle  of  the  cornual  canal. 

The  terminations  of  interstitial  pregnancy  are  determine^  to'  great 
degree  by  the  locality  of  the  imbedding  site.  In  the  utero-interstitial 
form  the  ovum  may  abort  into  the  uterine  cavity,  may  very  rarely  grow 
into  the  uterine  cavity  and  then  develop  to  maturity,  the  fetus  occupying 
the  cavum  uteri,  the  placenta  still  fast  in  the  cornua,  or  the  uterine  horn 
may  rupture  into  the  peritoneal  cavity.  In  the  interstitial  form  proper 
rupture  of  the  cornua  is  the  common  termination,  though  abortion  into 
the  uterus  may  occur,  and  the  death  of  the  ovum  with  the  formation  of 
a  cornual  mole  does  occasionally  take  place. 

In  the  tubo-interstitial  form,  rupture  is  the  usual  termination,  al- 
though incomplete  tubal  abortion  may  occur. 

If  the  pregnancy  be  utero-interstitial,  there  is  a  distinct  diaphragm 
of  tissue  separating  the  fetal  sac  from  the  uterine  cavity,  the  membrane 
being  apparently  formed  by  the  endometrium  and  a  portion  of  the  mus- 
cular ring  composing  the  cornua.  This  latter  may  present  the  appearance 
of  a  distinct  os,  rather  resistant  to  dilatation,  and  through  which  the 
fetal  membranes  may  be  felt. 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


71 


J.  C.  Webster,15  in  discussing  interstitial  pregnancy,  mentions  the 
possibility  of  the  ovum  extending  into  the  uterus  and  thus  developing 
partly  in  the  tube  and  partly  within  the  uterine  cavity.  In  other  cases 
Webster  has  seen  communication  between  the  uterus  and  the  fetal  sac 
closed  by  a  wall  formed  by  the  decidua;  and  in  still  another  group  the 
communication  may  remain  patent  and  be  only  closed  off  by  the  fetal 
membranes  themselves. 

It  has  been  the  good  fortune  of  the  writer  to  observe  three  cases  of  in- 
terstitial pregnancy,  illustrating  these  terminations.  One  was  of  the 
utero-interstitial  type,  and  will  be  reported  in  detail  in  the  chapter  on 


GerI'ki.dte-    V   .Sct-]>vH»» 


Fig.    32. — Schematic    Representation    of    an    Interstitial    Pregnancy    of    Four 
Months,  Which  Was  Removed  via  the  Uterine  Cavity.     (Author's  case.) 


diagnosis.  In  this  case  the  enlargement  of  the  uterine  horn  could  be  dis- 
tinctly felt  in  bimanual  examination.  At  the  right  cornu  a  distinct 
ring  of  fairly  firm  tissue  could  be  made  out.  This  was  penetrated  with 
a  dull  curette  and  a  placental  forceps  introduced  through  the  opening, 
and  a  normal  four  months'  fetus  with  its  placenta  and  membranes  was 
extracted.  The  myometrium  was  greatly  thinned  out.  The  placenta 
presented  a  characteristic  appearance,  being  much  flattened  and  having 
at  one  side  a  long  finger-like  prolongation,  which  had  extended  through 
the  uterine  cornu  and  had  evidently  been  attached  for  a  considerable 
distance  along  the  lateral  aspect  of  the  tube.     (Fig.  32.) 

The  second  case  was  one  in  which  there  had  been  the  ordinary  evi- 
dence of  extra-uterine  pregnancy — amenorrhea,  followed  by  spotting  and, 
severe  right  sided  pelvic  pain.     The  symptoms  subsided  after  a  few 


y2  EXTRA-UTERINE  PREGNANCY 

weeks,  but  a  dull  pain  in  the  right  iliac  fossa  finally  brought  the  patient 
to  the  writer.  The  uterus  was  found  slightly  enlarged  and  there  was 
a  smooth,  tender,  fixed  mass  in  the  right  cul  de  sac.  Diagnosis  of 
terminated  ectopic  pregnancy  was  made  and  operation  advised  and  ac- 
cepted. The  mass  which  had  been  palpated  through  the  vagina  was 
found  to  be  an  unilocular  ovarian  cyst,  eight  centimeters  in  diameter, 
which  was  densely  adherent  to  the  right  tube  and  broad  ligament.  The 
right  uterine  cornu  was  bulged  out  in  a  rounded  form,  the  swelling  being 
inside  the  attachment  of  the  round  ligament.  In  the  middle  portion 
there  was  found  a  recent  cornual  mole,  one  centimeter  in  diameter.    This 


Fig.  33—  A  Mole  Pregnancy  in  the  Right  Uterine  Cornu.  Incision  through  the 
uterine  wall  shows  the  ovum  in  situ.  Pregnancy  associated  with  an  adherent 
ovarian  cyst.     (Author's  case.) 

was  shelled  out,  the  cornu  curetted,  and  the  opening  closed.  The  ovarian 
cyst  was  removed.  The  cornual  mole  was  found  to  consist  of  blod  clot, 
decidual  cells,  and  chorionic  villi.  No  embryo  was  demonstrable.  (Fig. 
33-) 

The  third  case  was  that  of  a  lady  of  36,  who,  without  previous  his- 
tory of  ectopic  pregnancy,  with  the  exception  of  pelvic  pain  for  two 
weeks,  suddenly  suffered  a  most  violent  attack  of  pain  in  the  left  side 
of  the  pelvis,  with  syncope  and  rapid  collapse.  A  diagnosis  of  ruptured 
ectopic  pregnancy  was  made  upon  the  symptomatology  alone,  and  the 
patient  was  subjected  to  immediate  operation.  There  was  an  abundance 
of  free  blood  in  the  peritoneal  cavity,  and  upon  exposing  the  uterus,  the 
entire  anterior  surface  of  the  left  cornu  was  seen  to  be  literally  blown 
out.     The  cornu  was  represented  by  a  jagged,  stellate  laceration,  from 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY       73 

the  edges  of  which  blood  was  flowing,  and  from  which  protruded  bits 
of  decidua.  The  cornu,  with  the  attached  tube,  was  excised,  and  the 
wound  closed,  the  patient  making  an  uneventful  recovery.  No  embryo 
was  found,  but  on  examination  of  the  excised  tissue,  the  uterine  cornu 
showed  the  presence  of  decidua  and  many  chorionic  villi.  The  tube  was 
the  seat  of  an  old  endosalpingitis,  but  presented  no  evidence  of  de- 
cidual reaction.    (Fig.  34.) 

In  the  three  cases  just  reported,  the  rupture,  contrary  to  usual  re- 
ports, was  on  the  anterior  aspect.    In  the  first,  the  thinning  of  the  uterine 


Fig.  34. — An  Interstitial  Pregnancy  Which  Had  Ruptured,  Literally  Blowing 
the  Anterior  Uterine  Wall  into  Fragments.  Very  profuse  hemorrhage  into 
the  peritoneal  cavity.     (Author's  case.) 

wall,  though  not  seen,  was  definitely  felt  to  be  most  marked  on  the  an- 
terior aspect.  In  the  second  case,  the  cornual  mole  lay  just  beneath  the 
surface  on  the  anterior  uterine  wall.  In  the  third  case,  the  rupture  took 
place  entirely  in  the  anterior  wall  of  the  cornu. 

The  Pathology  of  Ovarian  Pregnancy. — It  has  been  stated  that 
ovarian  is  the  rarest  form  of  ectopic  pregnancy,  except  perhaps  the  cer- 
vical variety,  which  is  almost  unique.  Norris  1Q  in  1909  reported  nine- 
teen positive  cases  in  the  literature,  when  all  those  which  did  not  com- 
ply with  all  the  criteria  of  this  form  of  gestation  were  excluded.  Lock- 
yer  17  has  surveyed  the  literature  from  1909  to  1917,  and  finds  during 
this  interval  22  genuine  cases,  making  a  total  of  42;  since  191 7  the  only 
reported  case  in  literature  available  to  the  writer  is  that  of  Wynne  and 
Meyer,18  who  thus  add  one  case. 


74  EXTRA-UTERINE  PREGNANCY 

It  is  the  growing  belief  among  students  of  this  subject  that  ovarian 
pregnancy  is  not  so  rare  as  has  been  thought  in  the  past,  and  that  many 
specimens  which  have  been  dismissed  with  a  diagnosis  of  ovarian  hema- 
toma, after  a  cursory  microscopic  examination,  are  in  reality  cases  of 
ovarian  pregnancy,  in  which  the  products  of  conception  have  been  ex- 
truded from  the  follicle  or  have  become  degenerated.  The  earlier  cases 
of  ovarian  pregnancy,  those  reported  before  the  classic  one  of  Van 
Tussenbroek,  are  usually  excluded  from  modern  statistics  because  of  the 
paucity  of  the  information  regarding  the  nature  of  the  specimen  and 
because  they  do  not  fulfil  all  of  the  criteria  demanded  by  the  most  metic- 
ulous pathologists.  As  early  as  1878  Spiegelberg  10  established  certain 
conditions  which  must  be  fulfilled,  if  the  specimen  in  question  is  to  be  re- 
garded as  one  of  proven,  primary  ovarian  gestation.  Spiegelberg's  con- 
ditions were  that  (1)  the  tube  on  the  affected  side  must  be  intact;  (2) 
the  fetal  sac  must  occupy  the  position  of  the  ovary;  (3)  it  must  be  con- 
nected with  the  uterus  by  the  utero-ovarian  ligament ;  (4)  definite  ovarian 
tissue  should  be  found  in  the  sac  wall. 

To  these  criteria  Williams  20  adds  the  very  important  condition  that 
ovarian  tissue  must  be  present  in  several  portions  of  the  sac  wall  at  some 
distance  from  one  another.  This  requirement  is  necessary,  for  the  rea- 
son that  in  certain  cases  of  tubal  or  broad  ligament  pregnancy  the  ovary 
may  become  flattened  out  and  to  a  certain  extent  become  incorporated  in 
the  sac  wall.  Norris  demands,  in  addition,  that  the  tube  on  the  affected 
side  should  not  only  be  intact,  but  should  be  microscopically  free  from 
any  evidence  of  gestation.  More  recent  demands  that  an  embryo  must 
be  found  are  not  justifiable,  since,  in  a  large  number  of  cases  of  ectopic 
pregnancy  of  all  varieties,  the  embryo  is  lost  in  blood  clot  and  is  not 
demonstrable. 

When  it  is  considered  that  many  of  these  specimens  come  to  the 
pathologist  at  a  time  when  the  pregnancy  is  an  advanced  one,  the 
anatomical  relations  distorted  by  the  fetal  sac,  the  tissues  flattened  and 
thinned  out,  and  the  entire  mass  surrounded  by  adhesions,  it  will  be  re- 
alized how  difficult  it  is  to  find  a  case  which  complies  with  all  the  re- 
quirements deemed  necessary  to  confirm  its  genesis. 

When  the  operation  has  been  performed  days  or  weeks  after  rupture 
of  the  sac  wall  has  taken  place  with  the  escape  of  the  embryo,  the  involu- 
tion changes  in  the  sac  wall  themselves  are  sufficient  to  obliterate  the 
evidence  of  ovarian  origin  of  the  pregnancy.  For  these  reasons,  it  is 
probable  that  ovarian  pregnancy  is  not  nearly  so  uncommon  as  is  stated 
in  the  literature,  but  in  the  light  of  our  present  knowledge  of  the  con- 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY       75 

dition,  no  case  is  to  be  accepted  as  positive  which  does  not  conform  to  all 
of  the  criteria  as  laid  down. 

Primary  ovarian  pregnancy  is  the  result  of  the  fecundation  of  an 
ovum  while  it  is  still  confined  within  the  graafian  follicle.  This  state- 
ment, originally  made  by  Van  Tussenbroek,21  has  been  confirmed  by  all 
subsequent  investigators,  Norris  finding  eleven  of  the  nineteen  cases  re- 
garded by  him  as  being  positive  to  have  had  this  origin. 

Leopold  has  suggested  that  in  certain  cases  a  centrally  located  follicle 
may  rupture  into  a  more  superficially  located  one,  the  ovum  in  the  for- 
mer not  being  expelled,  but  being  fertilized  in  its  original  location  by  a 
spermatozoon  which  gains  access  through  the  superficial  follicle.  Hewet- 
son  and  Lloyd  22  believe  that,  after  fertilization,  the  phagocytic  ovum 
may  burrow  into  another  or  deeper  portion  of  the  ovary.  Both  these 
hypotheses  lack  confirmation.  The  etiology  of  graafian  follicle  im- 
pregnation has  been  well  expressed  by  Caturani,23  who  holds  that  the 
condition  results  from  ovarian  inflammation,  especially  peri-ovaritis. 
The  resistance  of  ovarian  tissue  so  affected  to  rupture  by  the  ripening 
follicles  and  the  subsequent  formation  of  follicular  cysts  are  well  known. 

Caturani  thinks  that  it  is  quite  possible  that  the  opening  in  the  ma- 
ture follicle  may  be  insufficient  to  allow  the  exit  of  the  ovum,  or  inci- 
dental disease  of  the  granulosa  or  of  the  theca  folliculi  may  render  the 
escape  of  the  ovum  impossible.  When  the  ovum  in  the  follicle  has  been 
fertilized,  the  latter  immediately  undergoes  conversion  into  a  true  corpus 
luteum,  being  lined  with  lutein  cells. 

The  corpus  luteum  is  rarely  perfectly  formed,  by  reason,  probably, 
of  the  early  small  hemorrhages  about  the  ovum,  as  well  as  the  erosive 
action  of  the  trophoblast,  whose  cells  rapidly  penetrate  the  layer  of  lutein 
cells,  in  order  to  invade  the  surrounding  vessel  walls  and  open  blood 
spaces,  from  which  the  developing  chorionic  villi  may  derive  nutriment 
for  the  embryo.  Between  the  ovum  and  the  lining  of  the  follicle  there 
is  always  noted  a  layer  of  fibrin,  degenerated  cells,  and  blood. 

The  chorionic  villi  are  found  attached  to  the  ovum,  with  their  distal 
ends  penetrating  the  layer  of  fibrin  and  blood  clot,  and  in  various  areas 
entering  blood  spaces  in  the  ovarian  stroma,  just  as  in  tubal  pregnancy. 

Placentation  in  ovarian  pregnancy  probably  follows  the  same  course 
as  in  uterine  or  tubal  pregnancy,  except  that  the  greater  vascularity  of 
the  ovum  permits  of  more  complete  placental  attachment  and  a  conse- 
quent more  definite  blood  supply  to  the  ovum.  As  to  the  formation  of 
decidua  in  the  ovary,  while  the  question  cannot  be  said  to  have  been  ab- 
solutely determined,  the  views  of  nearly  all  those  who  have  recently 
studied  this  matter  coincide  in  the  belief  that  in  the  ovary,  as  in  the  tube, 


76 


EXTRA-UTERINE  PREGNANCY 


no  true  decidual  reaction  takes  place,  but  that  there  is  formed  a  tissue, 
consisting  of  fibrin,  lutein  cells  and  masses  of  trophoblast,  which  may 


Uterine  end 


Tree  ftmbr,  end. 


Cloi  containing 
chorionic  villi 


Rupture 


Site  of  rupture 
Posterity  view 


Fig.  35.— Ovarian   Pregnancy:   Posterior  View.     From  Mall  and  Cullen. 

be  termed  a  pseudo  decidua,  and  which  is  the  expression  of  the  reaction  of 
the  ovarian  tissue  to  the  irritation  produced  by  the  erosive  action  of  the 
trophoblast. 


CK 

^*"*^*^- 

t^y^r-g? 

jS?f---' 

*S>-Jk 

||g^       /     ' 

Blc  ,-- 

F'hjS 

—31c 

-  Ci 

G. 

\. 

e*tt+*ZiI~**'~" 

SI'S/ 

s-J& 

«*tL^- 

Fig.  36.— Ovarian  Pregnancy:  Macroscopic  Section.    From  Mall  and  Cullen. 

The  duration  of  ovarian  pregnancy  is  in  the  main  longer  than  that 
of  the  tubal  variety,  by  reason  of  the  different  nature  of  the  tissues  en- 
closing the  embryonal  sac.     The  ovary  is  far  more  elastic  and  resilient 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


77 


These  facts  will  account  for  the  longer 


•  'V' '  &■  /$0&t'^''*S^ ■'■  '■'■'- 


:      :      _i.:  ~     ~Z~;H^~ 


Fig.  37. — Ovarian  Pregnancy:  Mi- 
croscopic Section.  From  Mall 
and    Cullen. 


than  the  tube,  as  evidenced  by  its  distention  in  cases  of  dermoid  cysts. 
The  substance  of  the  ovary  is  also  so  much  thicker  than  the  tube  wall 
that  penetration  of  the  former  by  chorionic  villi  is  most  improbable, 
while  in  the  latter  it  is  the  rule. 
duration  of  ovarian  pregnancies, 
many  of  them,  indeed,  going  to  term. 
The  typical  histological  characteris- 
tics of  ovarian  pregnancy  are  well  il- 
lustrated by  accompanying  drawings, 
taken  from  Mall  and  Cullen.  24 

When  rupture  of  an  ovarian  preg- 
nancy occurs,  it  is  occasioned  in  the 
same  way  as  in  tubal  pregnancy,  and  is 
well  expressed  by  Rubin  25  as  follows : 

1.  The  invasion  of  the  syncytium 
into  blood  vessels  may  cause  intracap- 
sular or  extracapsular  bleeding. 

2.  The  sac  may  become  thinner  and  no  longer  able  to  resist  the  in- 
creasing pressure  of  the  growing  ovum.  The  intraperitoneal  bleeding 
may  be  very  slight,  or,  as  in  ruptured  tubal  pregnancy,  severe.  In  the 
former  instance  the  process  may  go  on  to  resolution  or  undergo  inflam- 
matory change. 

The  Pathology  of  Pelvic  Hema- 
tocele.— Collections  of  blood  in  the  pel- 
vis were  treated  as  clinical  entities  until 
the  work  of  Lawson  Tait  convinced  the 
profession  that  such  a  condition  merely 
represented  a  terminal  pathology  of  ec- 
topic pregnancy.  This  view  was  held 
until  it  was  found  that  occasional  pelvic 
hemorrhage  resulted  from  ovarian  and 
tubal  hemorrhage  not  connected  with 
pregnancy.  Indeed  Bovee  26  reports  19 
cases,  1 5  tubal  and  4  ovarian,  of  hemor- 
rhage from  the  tube  and  ovary  that 
could  not  be  diagnosed  as  ectopic  preg- 
nancy at  the  time  of  operation.  In  12  of 
these  cases,  microscopic  reports  were 
positive  as  to  ectopic  pregnancy  in  but  2. 
On  the  other  hand,  Caturani  27  analyzed  one  hundred  cases  of  speci- 
mens   of    tubes    and    adnexa    removed    after    clinical    diagnosis    of 


— -- 

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-01 

.c/' 

,".  ?*.       V.  '?%*    '-»,{       i-jl 

*     •■•->-**-    i,  ■«     ,9    V     "%       ",. 

*         *             '    v«-     J>    *     :"^ 

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XI 

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I'           :        '          -^                                           ^       '*''                                   ^*        .      #K       "          "                    *          *      j 

2.       -            :-'-'-       ■'     *      '                       •       ~  ^       -          ^    l          «'■           '           ^ 

v^:"--*- ---"'"•  '-"?'  "^"--r"-" -~.-r > « ■ 

.               .         ■                                        : 

-Blc 

<x£&L 

Fig.  38. — Ovarian  Pregnancy:  Mi- 
croscopic Section.  From  Mall 
and   Cullen. 


78 


EXTRA-UTERINE  PREGNANCY 


ectopic  pregnancy,  and  only  fifteen  failed  to  produce  positive  micro- 
scopical evidence. 

When  the  literature  of  this  interesting  question  is  summed  up,  it 
appears  that  the  vast  majority  of  pelvic  hemorrhages  have  their  origin 
in  some  variety  of  ectopic  pregnancy,  but  there  remains  a  considerable 

number  in  which  clinical  and 
pathological  evidence  of  preg- 
nancy is  absolutely  lacking. 

Hematocele  has  been  de- 
fined as  an  organized  collec- 
tion of  blood  in  the  pelvis, 
and  these  collections  have 
been  divided  into  encapsu- 
lated, diffuse,  and  solitary 
hematocele,  the  encapsulated 
form  being  the  one  usually 
met  with.  Its  genesis  is  that, 
following  tubal  abortion  or 
tubal  rupture,  free  blood  en- 
ters the  peritoneal  cavity  and 
sinks  by  gravity  into  the 
pouch  of  Douglas.  By  its 
presence  the  blood  sets  up  an 
irritative  peritonitis  with  per- 
itoneal exudate  and  the  for- 
mation of  adhesions.  Fur- 
ther hemorrhage  from  the 
tube  augments  the  clot  and 
adds  to  the  exudate  and  the 
number  of  adhesions.  The 
final  result  is  a  dense  mass 
of  coagulum,  firmly  bound  together  in  layers  by  exudate  and  adhesions, 
the  affected  tube  and  its  ovary  together  with  coils  of  intestine  being 
firmly  atached  to  its  surface. 

Hematocele  formation  most  commonly  follows  tubal  abortion,  by  rea- 
son of  the  slowness  of  the  accumulation  of  blood  in  these  cases,  but  it 
may  be  associated  with  rupture  of  the  tube  in  instances  when  the  hemor- 
rhage is  not  rapid  and  profuse. 

If  the  collection  of  blood  be  small,  the  hematocele  will  be  limited 
to  Douglas'  pouch,  extending  laterally  only  on  the  side  of  the  affected 
tube:     If  the  blood  be  abundant,  the  hematocele ,  may  attain  great  size 


^ ':''•;': 

jm&M 

^s^"':''-   -v.  ":'■'.''  '. 

Am- 
Coe_ 

i" •    -~  •'-*.---.•''■•/•"'*•  •./;•'-.'.'*     ■•  ." . 

°       's,»t'j.:'' '  '••"  '      .     *.?-5g%M0*Si' 

Ch- 

''<;■■    -  C/'^;-';-v*^v:':          •        •  '•  ■ -- "": 

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31c- 

t^^frft^iAte^iiMB^gi--.-^.^..- .-:.-■-            •-..  -?Lr.  ?:■-*'- — 

Fig.    39. — Ovarian     Pregnancy:     Microscopic 
Section.    From   Mall   and   Cullen. 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


79 


and  fill  the  pelvis,  leaving  the  uterus  firmly  fixed  in  its  midst.  As  or- 
ganization proceeds,  the  entire  pelvic  viscera  may  be  involved  in  a  dense 
firm  mass  of  clot,  fibrin  and  peritoneal  adhesions.    (Figs.  41  and  42.) 

The  so-called  solitary  hematocele  has  been  described  (see  page  45) 
and  is  comparatively  uncommon. 

Hematocele  formation  offers  a  favorable  outcome  for  ectopic  preg- 
nancy, since  eventual  complete  absorption  of  the  clot  frequently  occurs. 


"W0^Wk^4 


la* 


Fig.  40. — Ovarian   Pregnancy:   Microscopic   Section.   From  Mall  and   Cullen. 

Secondary  rupture  of  a  rapidly  growing  hematocele  may,  however,  lead 
to  a  repetition  of  the  original  hemorrhage  into  the  peritoneal  cavity, 
with  disastrous  consequences. 

The  real  gravity  of  hematocele  lies  in  its  susceptibility  to  infection. 
Given  a  mass  of  blood  mixed  with  fibrinous  exudate  and  in  intimate  con- 
tact with  the  intestinal  walls,  infection  by  the  ubiquitous  colon  bacillus 
is  a  natural  sequence,  and  the  conversion  of  the  blood  clot  into  a  pelvic 
abscess  is  naturally  a  common  occurrence. 

In  most  cases,  though,  the  infection  is  of  such  low  grade  that  the 
tissues  do  not  break  down,  but  a  parametritis  develops,  with  extension 
of  the  inflammation  to  the  pelvic  connective  tissue.  This  in  time  un- 
dergoes resolution  and  leaves  in  its  train  merely  an  adhesive  pelvic  peri- 
tonitis, the  structures  being  firmly  bound  together  by  dense  adhesions. 

The  Pathology  of  Advanced  Ectopic  Pregnancy. — It  has  been 


So 


EXTRA-UTERINE  PREGNANCY 


previously  stated  that  far  advanced  tubal  pregnancy  without  rupture  of 
the  tube  is  a  rare  occurrence.  Under  these  circumstances,  the  pathology 
is  that  of  a  marked  distention  of  the  tube  wall,  the  thinning  out  of  the 
muscular  layer,  and  the  wide  distribution  of  connective  tissue  in  and 
between  the  muscle  bundles.     The  tube  becomes  involved  in  a  reactive 


Fig.  41. — Pelvic   Hematocele   Following   Tubal  Abortion.    From   Crossen. 


inflammation  and  is  usually  found  more  or  less  densely  adherent  to  sur- 
rounding structures.    Otherwise,  there  is  no  noteworthy  change. 

The  common  forms  of  advanced  ectopic  gestation  (and  these,  too, 
are  most  infrequent)  are  either  the  secondary  abdominal  types,  which 
follow  rupture  of  the  tube  with  the  expulsion  of  the  embryo  into  the 
peritoneal  cavity,  or  the  quite  rare  type  which  develops  when  the  ovum 
entire  is  extruded  from  the  tube  and  becomes  secondarily  implanted  upon 
tissues  possibly  remote  from  the  original  site.  Most  cases  of  abdominal 
pregnancy  seem  to  follow  either  rupture  into  the  broad  ligament,  develop- 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


81 


ment  continuing  between  the  folds  of  this  structure,  or  the  rupture  taking 
place  on  the  posterior  aspect  of  the  tube,  the  placenta  remaining  partially 
attached  to  its  original  site  within  the  tube  lumen  and  partially  becoming 
secondarily  attached  to  the  posterior  surface  of  the  broad  ligament.  In 
cases  reported  in  the  literature,  the  fetal  sac  is  frequently  described  as 


Fig.   42.— Blood    Mass    Surrounding    Ruptured   Tube.    From    Crossen. 

ending  in  a  pedicle,  composed  of  the  tube  and  the  broad  ligament  on  the 
affected  side. 

There  has  been  considerable  discussion  as  to  whether  fetal  develop- 
ment may  go  on  uninterrupted,  where  the  membranes  have  been  destroyed 
at  the  time  of  primary  rupture.  An  analysis  of  the  literature  leads  to  the 
conclusion  that,  while  the  fetus  in  these  cases  is  usually  enclosed  in  a  sac 
which  may  be  composed  either  of  the  fetal  membranes,  or  of  a  fibrinous 
exudate,  evidently  of  secondary  formation,  there  may  be  no  evidence  of 
any  embryonic  covering  whatever,  with  normal  growth  and  development 


82  EXTRA-UTERINE  PREGNANCY 

of  the  fetus.  This  is  well  shown  by  the  case  of  Bland-Sutton,28  in  which 
the  patient  went  to  full  term  and  on  operation  the  child  was  found  alive, 
having  escaped  from  the  amnion,  and  was  disporting  itself  among  the 
intestines.  When  a  sac  is  present,  it  is  usually  found  densely  adherent 
to  surrounding  intestinal  coils  and  to  omentum,  the  adhesions  being 
commonly  very  vascular. 

Placental  attachment  in  these  cases  is  usually  in  the  tube  or  along 
the  border  of  the  broad  ligament,  though  occasionally  the  entire  ovum 
may  have  been  extruded  from  the  tube  and  the  ovum  have  become  second- 
arily implanted  at  a  point  remote  from  its  original  site. 

(See  the  case  of  Lane,  page  43.) 

Extraperitoneal  abdominal  pregnancy  results  when  the  ovum  con- 
tinues to  develop  after  a  rupture  of  the  tube  between  the  folds  of  the 
broad  ligament.  As  the  embryo  grows,  the  leaflets  of  the  broad  ligament 
are  dissected  widely  away  from  the  pelvic  walls,  and  the  sac  develops 
under  the  peritoneum  and  becomes  what  Hart  has  termed  a  subperitoneo- 
pelvic  pregnancy,  until,  the  pelvic  brim  having  been  passed  by  the 
steadily  growing  fetus,  the  gestation  becomes  subperitoneo-abdominal. 
These  retroperitoneal  pregnancies  are  uncommon,  and,  as  pointed  out 
by  Williams,  are  in  grave  danger  of  infection  and  suppuration,  by  reason 
of  their  intimate  contact  with  the  rectum  and  bladder. 

When  abdominal  pregnancy  goes  on  to  term,  an  attempt  at  labor 
usually  occurs,  the  contractions  of  the  uterus  being  more  or  less  marked 
for  several  hours  and  then  subsiding.  After  the  subsidence  of  labor 
pains,  fatty  degeneration  of  the  placenta  takes  place,  resulting  in  the 
death  of  the  fetus,  which  may  then  undergo  various  changes  in  its  com- 
position. 

In  this  connection,  it  is  interesting  to  note  that  abdominal  pregnancy, 
terminated  by  operative  interference,  has  in  some  instances  resulted  in 
the  delivery  of  a  living  child.  Horsley29  has  recently  reviewed  the  litera- 
ture on  this  point  and  presents  the  records  of  105  cases  with  living  chil- 
dren, up  to  19 12.  The  majority  of  the  children  in  these  cases  lived  but 
a  few  hours  after  delivery  and  many  of  them  were  deformed.  A  few, 
however,  survived.  Horsley' s  case  is  here  quoted  as  an  excellent  illustra- 
tion of  this  interesting  outcome.  "H.  L.,  colored,  aged  27  years,  from 
Brunswick  County,  Virginia,  was  referred  by  Dr.  B.  W.  Dameron. 
Family  history  of  no  importance.  The  patient  had  been  married  ten 
years  and  had  menstruated  regularly,  except  when  pregnant.  The  first 
pregnancy  resulted  in  a  miscarriage  at  four  months  about  nine  years  ago. 
The  next  child  was  born  dead  at  full  term,  a  year  before  admission  to 
the  hospital.    The  first  menstruation  missed  since  these  pregnancies  was 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  83 

in  March,  191 1.  There  was  some  slight  bleeding  in  April  and  May, 
but  since  that  time  there  had  been  no  sign  of  menstruation.  There 
were  no  pains  in  the  abdomen  until  the  onset  of  labor,  and  the  patient  had 
no  reason  to  believe  that  the  pregnancy  was  abnormal  until  labor  began. 
On  the  first  of  December  she  had  cramp-like  pains  around  the  navel, 
which  were  very  severe.  There  was  no  pain  in  the  back.  The  feet  were 
slightly  swollen.  These  pains  continued  and  Dr.  Dameron  was  called  in. 
He  found  the  uterus  empty,  diagnosed  abdominal  pregnancy,  and  brought 
the  patient  to  the  hospital.  A  long  incision  was  made  a  little  to  the  left 
of  the  middle  line.  The  intestines. and  omentum  tended  to  protrude.  The 
anesthetic  was  given  lightly,  as  the  patient's  condition  was  considered 
dangerous  and  she  was  not  thoroughly  relaxed.  After  packing  away  the 
intestines  and  omentum,  the  baby  was  found  lying  largely  to  the  left  of 
the  middle  line  and  floating  among  the  intestines,  covered  only  by  a  thin 
membrane,  which  also  surrounded  the  placenta.  In  order  to  save  the 
child,  the  delivery  was  accomplished  as  rapidly  as  possible.  The  head 
was  towards  the  pelvis  and  was  lifted  up  with  the  hand,  at  the  same 
time  rupturing  the  membrane.  The  cord  was  clamped  and  the  child 
was  given  to  Dr.  M.  L.  Anderson  for  resuscitation.  The  baby  was  a  boy 
weighing  six  pounds  and  had  no  deformity.  There  were  a  few  adhesions 
of  the  intestines  and  omentum  to  the  sac;  these  were  separated  and 
ligated  where  they  were  vascular.  The  placenta  and  the  sac  had  a  dis- 
tinct pedicle  from  the  left  broad  ligament.  The  pedicle  was  ligated  and 
the  placenta  and  membranes  were  removed.  The  condition  resembled 
very  much  an  ovarian  tumor,  in  which  the  child  and  placenta  might  be 
said  to  constitute  the  contents  of  the  tumor.  The  wound  was  closed  in 
layers  with  catgut,  and  as  there  was  some  muddy  fluid  present,  a  drain- 
age tube  was  placed  in  the  cul  de  sac  through  a  stab  wound  in  the  right 
flank.  Mother  and  child  were  in  excellent  condition  when  discharged 
from  the  hospital  on  January  22,  191 2,  and  both  are  well  now,  De- 
cember 17,  1912,  more  than  a  year  after  the  operation." 

Abdominal  pregnancy  may  follow  normal  uterine  implantation  of  the 
ovum,  after  rupture  of  the  uterus,  an  accident  usually  brought  about  by 
instrumental  attempts  to  induce  abortion.  As  this  condition  is  not  strictly 
ectopic  pregnancy,  it  is  merely  mentioned,  and  illustrated  by  the  case  of 
Bishkow,30  which  was  as  follows :  "At  about  four  weeks'  pregnancy 
catheters  introduced  either  perforated  the  fundus  or  caused  a  local 
necrosis,  followed  by  perforation,  with  expulsion  of  the  products  of 
conception  into  the  peritoneal  cavity.  A  portion  of  the  placenta  suffi- 
cient to  keep  the  fetus  viable  retained  its  attachment  to  the  endometrium. 
The  rest  protruded  from  the  perforation  and,  by  partially  filling  up  this 


84  EXTRA-UTERINE  PREGNANCY 

opening,  controlled  to  some  extent  the  hemorrhage.  There  must  have 
been  a  slow,  continuous  bleeding,  for  a  large  amount  of  blood  was  found 
in  the  peritoneal  cavity  and  there  was  absence  of  any  severe  shock.  The 
fetus  and  the  greater  part  of  the  placenta  lying  extra-uterine  became, 
in  time,  covered  by  a  fibrinous  deposit,  which  formed  a  false  sac.  The 
day  preceding  operation  this  sac  ruptured  and  expelled  the  fetus  into 
the  peritoneal  cavity.  The  size  of  the  uterine  cavity  as  compared  with 
the  size  of  the  fetus  shows  that  for  a  period  of  about  four  months  the 
fetus  remained  viable  in  the  peritoneal  cavity." 

Changes  in  the  Tissues  the  Result  of  Ectopic  Pregnancy. — 
Chorio-epithelioma  may  develop  primarily  in  a  tube  which  has  been  the 
site  of  a  tubal  pregnancy,  the  focus  of  the  growth  being  at  or  near  the 
placental  site ;  occasionally,  indeed,  such  neoplasm  may  originate  at  some 
point  remote  from  the  tube,  just  as  in  similar  instances,  where  these 
tumors  succeed  normal  pregnancies. 

Primary  chorio-epithelioma  of  the  tube  is  fairly  common,  Leipman  31 
reporting  18  cases  up  to  1914.  This  condition  has  been  studied  by 
Hartz,32  who  reports  a  typical  case:  "A.  S.,  34  years  of  age,  white,  mar- 
ried. She  began  to  menstruate  at  13  years ;  was  regular  and  normal.  The 
patient  had  been  married  for  twenty  years,  had  six  normal  pregnancies, 
and  four  abortions.  The  last  pregnancy  terminated  in  abortion  four 
months  prior  to  the  onset  of  symptoms.  For  two  weeks  the  patient  com- 
plained of  vaginal  bleeding,  accompanied  by  severe  cramp-like  pains  in 
the  lower  abdomen.  A  diagnosis  of  ectopic  gestation  was  made  and 
operation  advised.  The  operation  was  performed  in  December,  19 13. 
The  abdomen  was  opened.  The  right  tube  showed  a  pregnancy  of  about 
six  weeks.  The  tube  and  ovary  were  removed  and  the-  abdomen  was 
closed.  The  pathological  report  of  the  specimen  is  as  follows :  The  mass 
consists  of  tube  and  ovary  and  gestation  sac  in  collapsed  condition.  The 
tube  measures  five  centimeters  in  length  and  four  centimeters  in  diameter 
at  its  widest  portion,  which  is  situated  near  the  fimbriated  end.  The  lumen 
is  filled  with  clotted  blood  and  the  walls  of  the  tube  are  considerably 
thickened.  Between  the  lower  border  of  tubes  and  ovary  there  is  an 
irregularly  shaped  sac  in  collapsed  condition,  measuring  five  centimeters 
in  diameter  and  lined  by  a  shaggy,  dark  red  membrane.  Adherent 
to  these  shaggy  villous-like  projections  are  masses  of  clotted  blood.  Un- 
der the  microscope  sections  of  the  tubal  wall  show  an  attached  placenta. 
At  points  the  chorionic  epithelium  extends  into  the  thin  wall  of  the  tube 
for  some  distance,  and  there  are  masses  of  these  cells  in  the  lumina  of 
some  of  the  veins.  This  involvement  of  the  wall  of  the  tube  is  more  ex- 
tensive than  usual  and  justifies  the  term  choriorepithelioma. 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


85 


Diagnosis. — Primary  chorio-epithelioma  of  tube  following  ruptured 
tubal  gestation.    The  patient  remained  well  after  two  years.     (Fig.  43.) 

In  Risel's 33  statistics  there  were  3.5  per  cent  of  primary  tubal 
chorio-epitheliomata  in  approximately  300  cases  in  the  literature. 

Decidua  formation  in  remote  tissue  occurs  after  extra-uterine  gesta- 
tion as  well  as  in  normal  pregnancy.  Outerbridge  34  reports  a  case  in 
which  portions  of  omentum,  which  had  been  excised  with  the  placenta 
during  an  operation  for  full  term  abdominal  pregnancy,  showed  dis- 
tinct islands  of  decidual  reaction  scattered  throughout  their  structure. 
Decidua  formation  has  been  reported  in  the  appendix  (Hirschberg, 
quoted    by    Outerbridge) 


and  in  a  parovarian  cyst 
(Taussig,  quoted  by  Out- 
erbridge), and  in  both  of 
these  cases  it  occurred 
in  connection  with  tubal 
pregnancy.  Outerbridge's 
specimen  showed  clearly 
defined  groups  of  decidual 
cells  scattered  throughout 
the  lower  portion  of  the 
omentum.  The  cells  were 
roundish,  ovoid  or  polyg- 
onal elements,  many  times 
larger  than  the  stroma 
cells  of  the  surrounding 
connective  tissue,  having 
perfectly  distinct  cell 
boundaries,  and  arranged  in  many  places  in  a  beautifully  tessellated 
manner.  Each  cell  has  a  layer  of  pink  staining,  finely  granular  cell  body; 
the  tendency  to  vacuolation  is  not  marked.  The  nuclei  are  regular 
in  form,  round  or  oval,  very  distinct,  and  show  a  fine  chromatic  net- 
work. 

Outerbridge's  discussion  of  the  etiology  of  decidual  masses  in  the 
omentum  is  well  put.  He  says,  "The  question  as  to  the  etiology  of  the 
decidual  masses  in  the  omentum  is  of  extreme  interest.  It  can  hardly 
be  maintained  that  the  decidua  has  been  formed  here  in  a  physiologic 
sense,  i.e.,  in  order  to  give  to  the  ovum  opportunites  for  attachment  and 
nourishment.  No  chorionic  villi  were  found  in  direct  attachment  to  this 
omental  decidua,  at  least  none  sufficiently  well  preserved  to  be  definitely 
diagnosed  as  such,  and  the  history  of  the  case  indicates  that  the  preg- 


Fig.  43. — Microscopic  Section  of  Primary  Chorio- 
epithelioma    of   Tube.     From    Hartz. 


86 


EXTRA-UTERINE  PREGNANCY 


nancy  was  primarily  tubal  at  any  rate,  the  ovum  reaching  its  final  resting 
place  in  the  abdominal  cavity  only  after  it  had  undergone  several  months 
of  development;  the  attachments  which  it  then  formed  to  the  omentum 


Fig.  44. — Decidual  Tissue  in  the  Appendix.     From  Outerbridge. 


Fig.  45. — Decidual  Tissue  in  a  Parovarian   Cyst.     From  Outerbridge. 

must  therefore  be  considered  purely  secondary  in  character.  Just  what 
influence  the  presence  of  the  developing  ovum  in  immediate  proximity 
to  the  omentum  and  ovary  had  in  producing  the  extremely  extensive  de- 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  87 

cidual  reaction  in  those  structures  is  hard  to  state,  though  that  this  fac- 
tor must  have  played  a  certain  role  seems  clear.  Loeb's  interesting  ex- 
periments have  shown — at  least  for  rabbits  and  guinea  pigs — that  the 
primary  factor  in  the  formation  of  uterine  decidua  is  the  presence  in 
the  circulating  body  fluids  of  a  hormone  developed  in  the  corpora  lutea; 
that  the  uterine  mucosa,  being  "sensitized"  by  the  presence  of  this  sub- 
stance, will  respond  by  the  formation  of  a  decidua  to  any  non-specific 
irritation — such  as  deep  incisions  into  the  uterine  wall,  the  introduction 
of  bits  of  glass  tubing  or  other  foreign  substances  into  the  uterine  cavity 
— even  though  the  ovum  be  entirely  excluded  from  entrance  into  the 
uterus  by  ligation  of  both  tubes.  If  this  theory,  that  the  sensitizing  in- 
fluence arises  in  the  ovary,  and  not  in  the  developing  ovum,  is  correct, 
the  seat  of  the  fetal  attachment  would  appear  to  exert  no  influence  what- 
ever on  the  formation  of  decidual  cells,  except  by  acting  as  a  mere  me- 
chanical irritation  to  the  fixed  connective  tissue  cells  of  that  region.  Just 
how  far  this  theory  applies  to  the  formation  of  extra-uterine  decidua 
cannot  be  stated ;  Loeb  has  not  been  able  in  his  experiments  to  produce 
decidua  outside  the  uterus,  but  the  practically  physiologic  development  of 
decidual  nodules  in  the  peritoneum  and  ovaries  in  normal  pregnancies 
would  seem  to  indicate  that  it  may,  in  part  at  least,  hold  true  for  these 
situations  as  well.  If  the  sensitizing  hormone  is  the  essential  factor, 
and  this  arises  in  the  corpus  luteum,  it  would  be  natural  to  expect  to  find 
the  ovarian  stroma,  at  least  that  of  the  ovary  containing  the  corpus 
luteum,  and  upon  which  its  secretion  must  work  in  its  fullest  concentra- 
tion, the  seat  of  extensive  decidual  change.  The  fact  that  this  change  has 
been  comparatively  seldom  observed  in  the  omentum,  however,  would 
seem  to  indicate  that  under  ordinary  circumstances  that  organ  either 
does  not  come  extensively  under  the  influence  of  the  ovarian  hormone, 
or  that,  if  it  does  come  under  this  influence,  mechanical  stimuli  are 
wanting  to  call  forth  a  decidual  reaction.  In  such. a  case  as  the  one  at 
present  under  consideration,  where  considerable  portions  of  omental  tis- 
sue have  come  into  closest  relationship  both  with  the  developing  ovum 
and  with  the  ovary  containing  the  corpus  luteum  graviditatis,  both  these 
factors  must  certainly  have  been  favored  to  the  fullest  degree,  and  this 
would  seem  to  offer  a  satisfactory  explanation  for  the  extensive  forma- 
tion of  omental  decidua." 

The  Fate  of  the  Embryo  in  Ectopic  Pregnancy. — In  the  great 
majority  of  cases  of  extra-uterine  gestation  the  embryo  is  destroyed 
during  the  early  weeks  of  development.  A  careful  study  of  the  matter 
is  that  of  Mall,6  which  will  be  freely  quoted  here :  "In  normal  implanta- 
tions in  the  tube  most  of  the  ova  are  destroyed  in  the  early  stages  by 


88  EXTRA-UTERINE  PREGNANCY 

the  hemorrhage  which  is  produced  for  their  nourishment.  If  the  dam 
built  up  by  the  trophoblast  is  sufficient  to  check  the  flood  in  part,  enough 
villi  will  remain  to  nourish  the  ovum.  When  the  tube  ruptures  into  the 
broad  ligament  the  space  for  the  chorion  becomes  sufficiently  large  for 
new  villi  to  grow  and  attach  themselves." 

In  all  cases  an  ovum  within  the  tube  is  at  a  decided  disadvantage, 
because  it  does  not  have  a  decidua  to  aid  in  producing  a  normal  im- 
plantation. The  importance  of  the  decidua  is  probably  greater  during 
the  early  months  of  pregnancy  than  in  the  last  half.  "Rupture  when 
it  occurs  on  the  free  side  of  the  tube,  throws  the  embryo  into  the  peri- 
toneal cavity  and  usually  terminates  its  career.  Broad  ligament  rup- 
tures offer  the  most  hopeful  outlook  for  the  continuance  of  embryonic 
life.  Whenever  the  degree  of  alteration  in  the  tube  wall  is  pronounced  and 
accompanied  by  marked  infection,  the  ovum  does  not  implant  itself  well, 
and  consequently  the  embryo  does  not  develop  normally,  but  becomes 
atrophied  and  degenerated.  The  more  severe  the  inflammatory  process, 
the  more  pronounced  is  the  reaction  upon  the  ovum." 

It  is  noteworthy  that,  among  the  specimens  studied  by  Mall,  far  more 
tubes  ruptured,  when  they  contained  normal  embryos,  than  among  those 
in  which  the  embryo  was  pathological ;  showing  that  a  live,  normal,  tubal 
embryo  is  probably  far  more  dangerous  to  the  mother  than  a  pathological 
one.  Pathological  ova  without  embryos  are  very  frequently  encountered 
in  examining  series  of  specimens  of  tubal  gestation.  Mall  found  that 
59  per  cent  of  his  specimens  fell  under  this  heading.  Most  of  such 
pathological  ova  are  collapsed  and  consequently  small,  less  than  10  mm. 
in  diameter.  The  pathological  condition  of  these  ova  is  that  they  are 
simply  disintegrating  and  degenerating. 

In  80  specimens  studied  by  Mall  there  were  16  per  cent  of  normal 
embryos,  25  per  cent  pathological  embryos  and  59  per  cent  pathologi- 
cal ova.  It  is  probable  that  the  pathological  ova  would  have  degenerated 
and  undergone  resorption,  had  they  not  been  removed  by  operative  meas- 
ures. It  is  also  probable  that  most  of  the  pathological  embryos  would 
have  been  absorbed  in  the  same  manner.  The  normal  embryos  usually 
are  destroyed  by  rupture  or  tubal  abortion,  but  may  survive,  and  it  is 
thought  that  about  3.3  per  cent  of  normal  embryos  go  on  to  full  term 
development,  either  within  or  without  the  tube;  10.5  per  cent  probably 
later  become  pathological  and  die,  and  2.2  per  cent  become  monsters. 
Von  Winckel  (quoted  by  Mall)  thinks  that  fully  one  half  the  fetuses  in 
ectopic  pregnancy  are  deformed,  the  most  common  deformities  being 
defects  of  the  hands  and  feet.  He  collected  87  cases,  and  found  that  in 
57  of  them  the  fetuses  were  much  deformed  and  in  12  were  markedly 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY       89 

monstrous.  Among  these  were  six  cases  of  hydrocephalus  and  one  each 
of  hydromeningocele,  encephalocele,  anencephalus,  omphalocele,  spina 
bifida,  and  hypospadia.  In  addition,  the  head  was  found  deformed  in 
57  specimens,  the  legs  in  44,  the  arms  in  35,  in  12  there  were  club  feet, 
and  in  4  cases  amniotic  bands.  The  placenta  was  usually  deformed, 
sometimes  multiple,  broad  and  thin,  or  short  and  thick,  and  often  very 
hemorrhagic. 

Cragin35  reports  a  case  of  full  term  ectopic  pregnancy,  in  which  the 
living  infant  suffered  from  a  small  umbilical  hernia,  asymmetry  of  the 
head,  and  congenital  dislocation  of  the  hip.  It  was  apparently  mentally 
normal  and  was,  as  Cragin  expresses  it,  "the  pet  of  the  ward." 

The  deformity  so  commonly  noted  among  fetuses  found  in  extra- 
uterine pregnancy  may  also  be  due  to  pressure.  "The  walls  of  an  ectopic 
gestation  sac  are  more  likely  to  exercise  injurious  pressure  on  the  fetus 
than  are  the' uterine  parietes.  On  the  other  hand,  it  may  be  that  the 
cases  in  which  the  fetus  has  shown  malformation  have  been  those  in 
which  rupture  of  the  sac  had  occurred,  and  the  infant  passed  into  the 
abdominal  cavity,  where  it  would  be  more  subject  to  compression  by 
the  material  structures." 

Ballantyne36  states  that  "In  the  event  of  the  extra-uterine  fetus  sur- 
viving the  effects  of  undue  pressure  plus  the  deficiencies  in  nutrition 
induced  by  faulty  placentation,  it  may  go  on  to  normal  development  at 
full  term  and  be  removed  from  its  aberrant  antenatal  situation  by  sur- 
gical measures."  It  has  already  been  stated  that  50  or  more  such  cases 
have  been  recorded.  When  a  correct  diagnosis  and  indicated  surgical 
treatment  are  not  carried  out,  the  fetus  dies,  or  fetal  death  may  occur 
from  any  one  of  the  factors  known  to  produce  the  accident  in  utero. 
When  such  fetal  death  does  occur  in  advanced  cases,  certain  terminal 
changes  take  place  in  the  body  of  the  child,  provided,  of  course,  it  is  not 
surgically  removed. 

These  changes  are  suppuration,  skeletonization,  lithopedion,  mum- 
mification, adipocere,  or  saponification. 

Suppuration  takes  place  in  a  considerable  number  of  retained  extra- 
uterine fetuses,  the  septic  process  originating  most  frequently  in  the 
sac  wall,  thence  spreading  to  the  fetus,  and  the  offending  organism  being 
probably  usually  the  colon  bacillus,  which  gains  access  to  the  sac  wall  by 
penetration  of  the  intestinal  wall  along  adhesion  lines. 

The  inflammatory  process  is  ordinarily  of  low  grade  type  and  even- 
tuates either  in  the  formation  of  a  pelvic  abscess,  which  points  into  the 
vagina  or  rectum,  portions  of  the  fetal  body  being  discharged  via  these 
cloacae;  or,  the  inflammation  slowly  subsides,  the  fetal  soft  parts  undergo 


90  EXTRA-UTERINE  PREGNANCY 

a  liquefaction  necrosis,  and  the  skeleton  remains  to  be  carried  as  an  inert 
foreign  body,  sometimes  for  a  term  of  years.  Occasionally  the  long 
bones  of  retained  abdominal  fetal  skeletons  penetrate  viscera  with  re- 
sulting peritonitis  of  varying  severity,  according  to  the  organ  involved 
and  the  amount  of  trauma  brought  about  by  the  irregular  end  of  a  fetal 
bone. 

The  following  case  of  Cullen's  37  is  typical  of  this  termination.  A 
colored  woman  of  33,  whose  previous  history  was  uneventful,  was 
admitted  to  Johns  Hopkins  Hospital,  May  3,  1907.  She  had  had  one 
difficult  full  term  pregnancy  13  years  before,  with  a  history  of  some 
puerperal  infection.  Three  years  previous  to  admission  the  patient  was 
supposed  to  be  pregnant,  exhibiting  the  characteristic  signs.  She  later 
developed  severe  abdominal  pain,  which  was  labor-like  in  character.  This 
lasted  for  five  minutes  and  then  suddenly  ceased,  the  patient  passing  only 
blood.  Immediately  after,  she  noticed  a  hard  tender  lump  in  the  right 
lower  abdomen.  This  lump  has  gradually  become  smaller,  as  has  also 
the  abdominal  enlargement.  There  is  burning  on  micturition,  which  is 
frequent  and  scanty,  and  the  urine  is  at  times  mixed  with  blood.  There  is 
a  profuse,  odorless  but  irritating  vaginal  discharge. 

On  examination  the  abdomen  was  found  distended  on  the  right  side 
by  an  irregular,  nodular  mass,  which,  on  palpation,  gave  a  feeling  of 
crepitus,  unusual  to  Cullen.  The  mass  was  irregular,  but  hard  like  a 
myoma.  On  pelvic  examination  the  cervix  was  found  to  be  firm,  the 
uterus  slightly  enlarged  and  in  retroposition.  On  the  right  side  was  a 
mass,  which  was  apparently  connected  with  the  body  of  the  uterus.  The 
structure  on  the  left  side  could  not  be  palpated.  From  the  history  and 
examination  the  condition  was  diagnosed  before  operation  as  an  abdomi- 
nal pregnancy.  The  patient  was  catheterized  when  under  ether,  and  a 
large  quantity  of  thick  tenacious  urine  was  obtained.  In  the  bladder 
the  catheter  also  encountered  something  which  felt  very  much  like  a  stone. 
Operation  May  4,  1907.  A  median  abdominal  incision  was  made.  The 
peritoneum  was  opened  and  at  once  disclosed  a  large  irregular  mass  in 
the  right  lower  abdomen,  with  the  omentum  densely  adherent  to  it.  After 
the  omentum  had  been  doubly  ligated  and  severed,  the  upper  portion  was 
pushed  back  out  of  the  way  and  the  parts  were  carefully  walled  off.  The 
large  and  small  bowel  were  found  to  be  densely  adherent  to  the  sac.  The 
small  bowel  was  dissected  away  as  carefully  as  possible,  but  the  outer 
coat  was  torn  about  12  inches  above  the  ileocecal  valve.  This  tear  was 
immediately  repaired  with  a  continuous  Pagenstecher  suture.  On  open- 
ing the  sac,  it  contained  a  large  number  of  fetal  bones.    After  removing 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


91 


the  greater  number  of  the  bones,  attempt  was  made  to  enucleate  the  sac. 
The  left  tube  and  ovary  were  now  removed  and  the  sac  on  the  right 
side  was  gradually  loosened  up.    The  bladder  was  found  densely  adherent 
and  connected  with  the  extra-uterine  mass.     After  being  freed  by  blunt 
dissection,  it  was  noted  that  one  of  the  long  bones  projected  into  the 
bladder  and  that  the  portion  within  the  bladder  was  covered  with  a  thick 
deposit  of  urinary  salts.     The  bladder  opening  was  closed  with  catgut 
and  with  a  continuous  Pagenstecher  su- 
ture.   The  enucleation  of  the  sac  was  con- 
tinued until  it  was  delivered  from  the  ab- 
domen.    The  large  bowel  was  then  ex- 
amined.   There  were  two  openings  in  the 
cecum,  one  at  the  junction  of  the  ileocecal 
valve.     The    vermiform    appendix    was 
thickened  and  indurated.    It  was  situated 
two   centimeters    from   this   hole   in   the 
cecum.     The  appendix  was  removed  and 
the  hole  in  the  bowel  closed  in  with  two 
continuous    Pagenstecher    sutures.      The 
second  opening  in  the  cecum  was  six  centi- 
meters   from  the  ileocecal  valve.     This 
was  drawn  up  into  the  wound  and  sutured 
in  a  similar  manner  with  two  continuous 
Pagenstecher  sutures.     The  holes  in  the 
bowel  had  been  made  by  the  ends  of  the 
long  bones,  which  had  ulcerated  through 
and  were  projecting  into  the  lumen.    Sec- 
tions from  the  wall  of  the  sac  show  that 
it  consists  partly  of  omentum,  partly  of 
granulation  tissue,  which  is  very  edema- 
tous.    The  right  ovary  is  edematous  and 
cystic  and  measures  6.5  x  5.5  x  3  centi- 
meters.    In  this  case  the  uterus  had  evi- 
dently ruptured  at  the  time  of  the  patient's  severe  pain,  and  the  fetus  had 
escaped  into  the  right  lower  abdomen.     A  slow  inflammatory  process 
had  gradually  developed,  and  eventually  the  ends  of  the  long  bones  had 
been  forced  through  into  the  bowel  and  bladder. 

The  interesting  termination  of  abdominal  pregnancy  known  as  litho- 
pedion  occurs  when  the  dead  fetus  of  variable  age  becomes  infiltrated 
with  calcium  salts  and  converted  into  a  more  or  less  completely  calcified 
mass.    The  condition  has  been  well  known  for  many  years,  an  interest- 


Fig.  46. — Fetal  Bones  Taken 
from  Abdomen  after  Rup- 
ture of  Pregnant  Uterus. 
From    Cullen. 


92  EXTRA-UTERINE  PREGNANCY 

ing  case  being  fully  reported  in  1586,  to  which  reference  has  been  made 
in  the  historical  section  of  this  book. 

These  partially  calcified,  partially  exsiccated  fetuses  may  be  carried 
by  the  mother  for  a  long  term  of  years,  without  marked  evidence  of  their 
presence.  Hayd's  38  case  had  been  carried  without  inconvenience  to  the 
bearer  for  33  years.  Van  der  Veer  and  McCabe  39  removed  at  autopsy  a 
lithopedion  carried  35  years,  the  specimen  lying  entirely  free  in  the 
abdominal  cavity,  except  for  a  slight  adhesion  of  intestine  and  peri- 
toneum. 

The  frequency  of  lithopedion  formation  is  difficult  to  determine, 
though  it  may  be  said  that,  as  abdominal  pregnancy  itself  is  a  rare  con- 
dition, operators  of  wide  experience,  seeing  but  very  few  cases  individ- 
ually, it  follows  that  this  unusual  termination  of  a  process  rare  in  itself 
must  be  quite  uncommon. 

Strauss  40  collected  38  cases  from  the  literature  from  1880  to  1900, 
and  Bainbridge  41  added  36  cases,  including  one  of  his  own,  from  1900 
to  1912,  a  total  of  74  cases.  The  relative  frequency  of  lithopedion  for- 
mation in  ectopic  pregnancy  is  estimated  by  Schrenk  42  as  1.8  per  cent,  or 
11  among  610  cases.  Schauta  (quoted  by  Bainbridge)  found  9  litho- 
pedions  among  626  cases,  or  1.5  per  cent. 

These  figures,  in  the  opinion  of  the  writer,  are  too  high,  although 
no  definite  statistics  can  be  offered  to  refute  them.  The  case  groups 
which  have  been  gathered  for  analytical  purposes  in  America  during  the 
past  few  years  are  of  some  value  in  estimating  the  relative  frequency  of 
such  termination.  In  a  summary  of  six  case  groups,  compiled  in  recent 
years  from  various  sections  of  the  country,  there  were  866  studied  cases 
of  extra-uterine  pregnancy,  with  no  lithopedions.  In  the  writer's  series 
of  207  cases  there  was  no  lithopedion.  It  seems  fair  to  assume,  there- 
fore, that  a  ratio  of  more  than  one  per  cent  is  entirely  too  high  and 
gives  a  false  estimate  of  the  frequency  of  such  pathological  change. 

This  entire  subject  remained  in  confusion  until  cleared  up  by  Kuchen- 
meister,43  who  in  1881  produced  a  masterly  monograph  originating  the 
classification  still  in  use.  Kuchenmeister  divided  these  tumors  into  three 
groups : 

1.  Lithokelyphos,  where  the  calcification  is  limited  to  the  membranes 
or  fetal  sac. 

2.  Lithokelyphopedion,  when  the  membranes  and  the  fetus  are  in- 
volved in  the  calcareous  process. 

3.  Lithopedion,  when  the  fetal  body  alone  is  involved  in  the  calci- 
fication. 

Lithokelyphos   follows  usually  the  broad  ligament  pregnancies,  or 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY       93 

those  in  which  intraperitoneal  development  of  the  ovum  goes  on  for 
some  time,  the  membranes  being  intact  and  the  liquor  amnii  present.  It 
is  supposed  that  the  presence  of  the  gestation  sac  sets  up  a  low  grade,  ir- 
ritative peritonitis,  which  in  turn  gives  rise  to  a  fibrinous  exudate,  cover- 
ing the  walls  of  the  sac  and  eventually  undergoing  calcareous  degenera- 
tion, possibly  as  a  terminal  change  following  a  fatty  degeneration.  In 
these  cases  the  macerated  fetus  can  sometimes  be  shelled  out  of  the  cal- 
careous envelope. 

In  lithokelyphopedion  both  fetus  and  sac  are  involved  in  the  calca- 
reous process.  The  genesis  of  this  condition  is  that  either  the  fetus  be- 
comes adherent  in  some  areas  to  its  enveloping  membrane  during  fetal 
life,  or  that  the  abdominal  gestation  sac  becomes  adherent  to  such  vis- 
cera as  have  high  absorptive  power,  such  as  the  small  intestine,  the 
liquor  amnii  rapidly  being  absorbed,  the  sac  wall  coming  into  intimate 
contact  with  the  fetus  and  joining  with  it  in  the  stony  change. 

True  lithopedion  results  when  the  fetus  has  escaped  from  its  mem- 
branes before  death  and  when  there  has  not  been  developed  about  it  the 
usual  false  sac  wall,  composed  of  fibrin  and  peritoneal  adhesions.  Of 
the  three  forms  the  first  and  third  seem  to  be  the  most  frequently  ob- 
served, while  the  seconcl  is  uncommon,  though  far  more  frequent  than 
formerly  supposed.  The  age  of  lithopedions  is  difficult  and  almost  im- 
possible to  determine,  unless  a  history  suggestive  of  the  rupture  of  an 
ectopic  pregnancy,  followed  by  some  evidence  of  false  labor,  is  elicited, 
with  the  dates  correctly  noted. 

These  objects  are  much  smaller  than  a  living  fetus  of  the  same  period 
of  growth,  owing,  of  course,  to  the  exsiccation  which  they  have  under- 
gone. The  same  factor  will  explain  their  comparative  lightness,  the 
weight  steadily  decreasing  as  moisture  is  abstracted,  until  the  extreme 
low  weight  point  is  reached,  after  which  the  accretion  of  lime  salts  from 
without  the  structure  may  eventually  materially  increase  its  weight. 

The  ultimate  result  of  lithopedion  formation  may  be  suppuration 
of  the  still  moist  fetal  sac,  with  skeletonization  of  the  fetus  after  a  period 
of  liquefaction  necrosis  of  its  soft  parts ;  or,  the  structure  may  remain, 
the  low  grade  peritonitis  excited  by  its  presence  soon  subsiding,  and 
the  lithopedion  being  carried  as  a  perfectly  innocuous,  and  in  many  in- 
stances a  totally  unsuspected  mass  in  the  abdomen,  until  the  death  of  the 
patient  from  some  intercurrent  disease.  It  is  regarded  as  a  favorable  ter- 
mination of  abdominal  pregnancy.  Very  rarely  the  fetus  undergoes  a 
saponification,  the  mechanism  of  which  is  obscure.  Under  the  proper 
conditions  (and  no  one  knows  what  the  proper  conditions  are)  the  fats 
of  the  fetal  body,  in  contact  with  ammonia,  evidently  a  decomposition 


94 


EXTRA-UTERINE  PREGNANCY 


product,  become  altered  into  a  thick  greasy,  soapy  substance,  which  en- 
tirely replaces  the  fetal  tissues.  This  condition  is  called  adipocere;  its 
genesis  is  not  understood  and  specimens  are  most  uncommon. 

A  typical  case  of  lithokelyphopedion  is  that  of  Hayd,38  who  operated 
upon  a  woman  67  years  of  age,  who  had  gone  through  a  false  labor  32 


Fig.  47. — Lithokelyphopedion.    From  Hayd. 

years  before  and  had  remained  in  good  health  since  until  some  weeks 
previous,  when  she  developed  steadily  increasing  abdominal  pain,  with 
ascites.  A  large,  hard  tumor  could  be  felt  rilling  the  whole  of 
the  pelvis,  particularly  on  the  left  side.  On  operation  there  was  re- 
moved a  globular  mass,  weighing  two  pounds  and  four  and  a  half  ounces. 
It  was  surrounded  by  a  dense,  hard  covering,  which  was  about  as  thick 
as  thin  cardboard,  and  by  letting  the  specimen  drop  upon  the  floor  the 
noise  made  was  as  if  a  solid  stone  had  fallen.  After  sawing  through  the 
outer  envelope,  the  fetus  was  seen  firmly  bent  upon  itself;  the  arms  and 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY       95 

legs  were  flattened  like  bands.  The  calcified  membrane  was  firmly  ad- 
herent to  the  head  and  spine  and  back  of  the  legs  and  arms.  The  abdo- 
men, chest,  side  of  head,  arms,  legs  and  fingers — and  even  finger  nails — 
were  in  perfect  preservation,  the  sex  being  determined  by  the  little  penis 
and  scrotum.  The  placenta  was  present,  the  cord  was  thin  and  glistening 
in  color,  and  was  unusually  well  preserved.    (Figs.  47-48.) 

A  case  of  true  lithopedion,  which  illustrates  the  usual  pathology  and 


Fig.  48. — Lithopedion  from  Sac  Shown  in  Fig.  47.    From  Hayd. 

appropriate  treatment,  is  that  of  Maier.44  "A  woman  of  40  had  two 
full  term  pregnancies,  the  labors  of  which  were  without  incident.  Her 
present  trouble  began  twelve  years  ago.  While  six  months  pregnant,  she 
fell  down  a  well  and  injured  her  abdomen.  Immediately  afterward 
she  suffered  from  severe  abdominal  pains  and  profuse  hemorrhages  from 
the  vagina.  These  symptoms  continued  intermittently  for  two  weeks, 
when  they  ceased.  During  this  time  no  material  was  discharged  that  in 
any  way  resembled  the  products  of  conception.  After  the  abdomen  had 
again  become  normal  in  size,  the  patient  noted  a  hard  mass  midway  be- 


96 


EXTRA-UTERINE  PREGNANCY 


tween  the  symphysis  and  the  umbilicus.  This  mass  was  about  the  size 
of  a  large  egg,  freely  movable,  did  not  appear  to  increase  in  size,  and  only 
on  strenuous  exertion  gave  rise  to  distress.  It  was  only  within  the  past 
year  that  the  patient  had  had  symptoms  sufficient  to  induce  her  to  con- 
sult a  physician.  These  were  confined  to  the  lower  quadrant  of  the  ab- 
domen and  of  no  definite  character.  In  the  presence  of  an  enlarged  ir- 
regularly nodulated  uterus,  a  dense  tumor  to  the  left  of  it,  and  the  hard 
movable  mass  floating  above,  a  diagnosis  of  fibroids  was  made.  Opera- 
tion, hysterosalpingo-oophorectomy,  at  St.  Joseph's  Hospital,  revealed 
the  hard  movable  body  to  be  a  calcified  fetus  that  floated  fairly  free  in 
the  abdominal  cavity,  just  above  the  brim  of  the  pelvis.    The  tip  of  the 


Fig.  49. — True  Lithopedion.     From  Maier. 


omentum  and  a  few  coils  of  the  intestines  were  lightly  adherent  to  its 
surface.  It  was  attached  by  a  short  calcified  pedicle,  the  remains  of  the 
umbilical  cord,  to  a  dense  mass  in  the  posterior  surface  of  the  left  broad 
ligament,  that  consisted  of  a  hard  calcareous  area,  the  former  placenta, 
the  tube,  and  the  ovary."    (Fig.  49.) 

To  summarize :  The  fetus  in  ectopic  pregnancy  usually  perishes  be- 
fore the  third  month.  Rarely,  it  may  develop  normally  to  term  and  be 
delivered  alive  by  abdominal  section,  or  it  may  grow  to  full  maturity, 
die  after  false  labor,  and  be  retained  for  a  variable  length  of  time  as  a 
foreign  body,  undergoing  generally  some  terminal  change  in  its  struc- 
ture.   (Figs.  50-51-) 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY 


97 


t\f\ 


Fig.  50. — Lithopedion  Lying  Undisturbed  in  the  Abdominal  Cavity.    From  Kelly. 


LITERATURE 


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Fig.  51. — Lithopedion  Removed  from  the  Abdominal  Cavity  Four  Years  After  a 

False  Labor.    From  Kelly. 
98 


PATHOLOGY  OF  EXTRA-UTERINE  PREGNANCY  99 

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et  d'obst.     1899.     p.  211,  537. 

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ioo  EXTRA-UTERINE  PREGNANCY 

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29.  Horsley,  J.  S.     Abdominal  Pregnancy  with  a  Living  Child.     Surg. 

Gyn.  Obst.     1913.     17:58. 

30.  Bishkow.     Jr.  Am.  Med.  A.     1919.     72:1668. 

31.  Leipman.     Handbuch  der  Frauenheilkunde.     1914.     v.  2:182. 

32.  Hartz,  H.  J.     Primary  Chorio-Epithelioma  of  Fallopian  Tube  Fol- 

lowing Ruptured  Ectopic  Gestation.     Surg.   Gyn.   Obst.      19 16. 
23  :6o2. 

33.  Risel.    Ztschr.  f.  Gebh.  u.  Gyn.     1905.    61  :i54.    Quoted  by  Hartz. 

34.  Outerbridge,  G.  W.     Decidual  Formation  in  the  Omentum  in  Sec- 

ondary Abdominal  Pregnancy.    Am.  Jr.  Obst.     1912.    65:212. 

35.  Cragin,  E.  B.    Am.  Jr.  Obst.     1900.    41  :74c 

36.  Ballantyne,  J.  W.     Manual  of  Antenatal  Pathology  and  Hygiene. 

Edinburgh,  1904.     p.  144. 
2,7-  Cullen,  T.  S.    Unusual  Cases  Illustrating  Points  in  Diagnosis  and 
Treatment.     Surg.  Gyn.  Obst.     19 15.     20:260. 

38.  Hayd,    H.    E.       Litho-Kelyphopedion.       Am.     Jr.     Obst.       1907. 

56:657- 

39.  Van  der  Veer  and  McCabe.    Alb.  Med.  Ann.     19 10.    p.  4. 

40.  Strauss.     Zur  Kasuistik  und  Statistik  des  Lithopediona.     Arch.  f. 

Gyn.     1903.     68:3. 

41.  Bainbridge,  W.  S.     Lithopedion.     Am.  Jr.  Obst.     1912.     65:31. 

42.  Schrenk.     Uber  Ektopische  Graviditas  Inaug.  Dis.,  1893.  Quoted 

by  Bainbridge. 

43.  Kuchenmeister.     Tiber  Lithopedion.     Arch.  f.  Gyn.     1881.     17: 

153,  359- 

44.  Maier,  F.  H.     Extra-uterine  Lithopedion.     Am.  Jr.  Obst.     191 5. 

72  :63c 


CHAPTER  V 

RECURRENT  EXTRA-UTERINE  PREGNANCY 

Twin  Ectopic  Pregnancy — Combined  Intra-  and  Extra-Uterine  Pregnancy — Compli- 
cated Extra-Uterine  Pregnancy — Tubal  Pregnancy  and  Fibroid  Tumors  of  the 
Uterus — Unique  Forms  of  Ectopic  Pregnancy — Hemorrhage  from  Ovary  or 
Tubes    Simulating  Ruptured    Ectopic    Pregnancy. 

The  causes  underlying  tubal  pregnancy  are  frequently  identical  in 
both  tubes  and,  should  one  tube  be  removed  for  the  relief  of  this  condi- 
tion, it  is  reasonable  to  suppose  that  the  other  tube  may  be  similarly  af- 
fected at  some  subsequent  period.  Indeed,  this  opinion  is  so  definite 
that  a  number  of  gynecologists  advocate  the  removal  of  the  unaffected 
tube  at  the  time  of  an  operation  for  extra-uterine  pregnancy,  as  a 
phophylactic  measure  against  recurrence  of  the  disease.  An  examination 
of  the  literature  on  this  point  brings  out  many  illuminating  details. 
Three  authors  have  thoroughly  investigated  this  phase  of  the  subject, 
and  the  writer's  views  are  based  largely  upon  their  work.  They  are 
Wassmer,1  Smith,2  and  Giles,3 

First,  as  to  the  frequency  of  recurrence  of  extra-uterine  pregnancy, 
versus  the  birth  of  full  term  children  subsequent  to  an  operation  for  tubal 
pregnancy.  Giles  found  that,  in  39  cases  of  ectopic  pregnancy,  whose 
history  had  been  traced  and  where  one  tube  or  ovary  was  removed,  five 
developed  ectopic  pregnancy  in  the  remaining  tube  with  operation  (12.8 
per  cent). 

Among  the  same  39  cases,  six,  or  15.4  per  cent,  developed  some 
lesion  of  the  remaining  appendage,  requiring  operative  relief.  Of  38 
cases,  however,  13,  or  34  per  cent,  later  gave  birth  to  living  children. 
Incidentally,  of  125  cases  studied  by  Giles,  in  which  unilateral  salpingo- 
oophorectomy  was  performed  for  various  lesions,  including  ectopic  preg- 
nancy, 33,  or  26  per  cent,  became  pregnant  later,  and  of  these,  8,  or  24 
per  cent,  were  extra-uterine  pregnancies. 

Essen-Moller 4  collected  39  cases,  in  which  subsequent  pregnancy 
was  possible.  Of  these,  only  two  suffered  from  repeated  tubal  preg- 
nancies, while  18,  or  46  per  cent,  have  had  uterine  pregnancies.  He 
quotes  Prochownik,5  who  had  twenty-five  normal  pregnancies  out  of  57 

101 


102  EXTRA-UTERINE  PREGNANCY 

women,  or  43.8  per  cent,  and  Engstrom,6  who  had  twenty  out  of  forty- 
three,  or  46.5  per  cent. 

Smith  7  in  a  later  paper  collected  144  cases  from  the  records  of  Ameri- 
can operators.  Of  these  144,  in  all  of  which  subsequent  pregnancy  was 
possible,  47  had  uterine  pregnancy  with  64  children,  and  there  were  21 
instances  of  repeated  ectopic  pregnancy.  The  statistics  of  P.  F.  Wil- 
liams show  that  among  58  cases  of  tubal  pregnancies,  7  developed  a 
subsequent  pregnancy  in  the  same  series,  a  ratio  of  extra-uterine  to  intra- 
uterine pregnancy  of  1  :5-5- 

The  thoughtful  analysis  of  this  subject  by  Smith  reveals  that,  among 
1608  cases  of  tubal  pregnancy  operated  upon  by  members  of  the  Ameri- 
can Gynecological  Society,  there  were  58  repetitions  of  the  accident,  or  3.6 
per  cent.  From  the  literature  Smith  has  collected  1390  authentic  cases, 
with  55  repetitions,  or  4  per  cent.  From  the  very  nature  of  the  case, 
it  is  difficult  to  obtain  figures  upon  this  point  that  are  above  criticism, 
since  it  involves  a  careful  following  up  of  patients  over  a  considerable 
number  of  years,  and  this  is  rarely  possible. 

Obviously  the  cause  of  repeated  ectopic  pregnancy  is  usually  identical 
with  the  cause  of  the  original  abnormal  implantation,  except  in  those  cases 
where  an  inflammatory  reaction  following  the  laparotomy  has  damaged 
the  remaining  tube,  which  previously  was  healthy. 

The  practical  point  in  this  connection  is,  whether  it  is  proper,  in  the 
interests  of  the  patient,  to  uniformly  remove  the  non-pregnant  tube  as  a 
routine  procedure  in  operation  for  tubal  pregnancy.  This  question  is  best 
decided  by  a  statistical  comparison  of  repeated  ectopics,  as  opposed  to 
intra-uterine,  since,  should  the  former  event  supervene,  it  is  obvious 
that  the  remaining  tube  is  at  least  patulous  and  offers  no  obstruction  to 
the  passage  of  the  ovum.  If  the  statistics  quoted  above  be  grouped,  it  is 
found  that  among  280  patients,  in  whom  future  pregnancy  of  any  variety 
was  possible,  35,  or  12.5  per  cent,  suffered  from  repeated  ectopic  gesta- 
tion, while  134  intra-uterine  pregnancies  occurred,  or  47.8  per  cent,  a 
ratio  of  about  1  to  4.  It  appears  then  that  about  one  woman  in  eight  who 
has  had  one  extra-uterine  pregnancy  may  expect  another,  whereas  one- 
half  the  total  number  have  the  possibility  of  future  normal  pregnancy. 

These  figures  are  overwhelmingly  in  favor  of  leaving  a  patient  apt 
for  future  conception  wherever  possible,  and  they  lead  to  the  dictum  laid 
down  by  the  writer  and  practiced  at  his  clinic,  which  is  as  follows :  First, 
that  the  immediate  recovery  of  the  patient  is  the  first  consideration,  and 
when  a  patient  is  in  serious  condition,  no  surgical  procedure  is  per- 
formed, except  the  minimum  one  required  to  combat  the  pathology 
present.     The  remaining  tube  is  therefore  never  removed  under  these 


RECURRENT  EXTRA-UTERINE  PREGNANCY  103 

circumstances,  unless  it  be  the  seat  of  such  grave  disease  as  to  possibly 
endanger  the  woman's  life. 

Second,  when  the  patient  is  in  good  surgical  condition,  the  non- 
pregnant tube  is  carefully  inspected,  and  should  it  be  apparently  hope- 
lessly damaged,  it  is  removed.  Indefinite  signs  of  preexisting  salpin- 
gitis, however,  do  not  constitute  an  indication  for  such  removal. 

Third,  inasmuch  as  ectopic  pregnancy  has  recurred  in  the  same  tube 
and  as  conservative  operations  in  the  tube  are  ill  advised  in  the  opinion 
of  the  writer,  the  entire  ectopic  tube  is  invariably  excised. 

An  interesting  case  of  repeated  extra-uterine  pregnancy,  which  oc- 
curred in  the  service  of  the  author,  was  that  of  a  Polish  woman  of  26, 
who  was  admitted  to  Frankford  Hospital  with  all  the  evidences  of  a  rup- 
tured tubal  pregnancy.  On  section,  the  left  tube  was  found  the  seat  of 
the  lesion,  intraperitoneal  rupture  having  taken  place.  The  right  tube 
presented  no  gross  lesions  and  was  not  removed.  The  left  one  was 
excised,  the  patient  making  an  uneventful  recovery.  Ten  months  later 
the  woman  was  readmitted  with  the  history  of  a  self  induced  abortion 
with  retained  placenta.  A  four  months'  placenta  was  removed  from  the 
uterine  cavity,  with  an  afebrile  convalescence.  Six  months  following 
this  operation  the  patient  was  admitted  for  the  third  time,  with  rather 
indefinite  signs  of  ectopic  pregnancy,  and  on  laparotomy  there  was 
found  an  incomplete  tubal  abortion  on  the  right  side.  The  right  tube 
was  excised,  with  recovery. 

There  are  instances  on  record  where  three  ectopic  pregnancies  have 
developed  in  one  patient,  but  a  close  examination  of  many  of  the  his- 
tories leads  to  serious  doubt  as  to  their  authenticity.  Two  cases,  how- 
ever, quoted  by  Smith,  seem  fairly  definite,  but  even  these  will  not  stand 
scientific  criticism.  The  histories  were  contributed  by  Peterson  and 
Brettauer.     Peterson's  case  is  as  follows: 

Patient  twenty-one  years  of  age;  has  always  been  in  good  health. 
She  was  married  December  26,  1908,  and  was  always  regular,  but  had 
had  some  dysmenorrhea.  She  had  an  attack  of  pain  in  the  right  side  in 
May,  1909.  She  had  skipped  a  period  and  began  to  flow,  and  was  seized 
with  pain  in  the  right  side.  Her  doctor  felt  a  mass  there,  but  she  was  not 
operated  upon  and  gradually  recovered.  The  appendix  was  removed 
six  months  later,  November  23,  1909.  The  next  attack  was  the  first 
of  May,  1 9 10.  She  skipped  a  period  and  was  taken  with  pain  in  the 
right  side.  She  went  to  bed,  and  after  further  pain  a  diagnosis  of  extra- 
uterine pregnancy  was  made,  and  she  was  operated  upon  May  22,  1910 
— a  year  after  the  first  attack  above  mentioned.  A  ruptured  ectopic 
pregnancy  of  six  weeks  was  found.     She  skipped  a  period  again  in  Jan- 


104  EXTRA-UTERINE  PREGNANCY 

uary,  191 1,  had  the  same  kind  of  pain  in  the  left  side,  a  bloody  discharge 
from  the  uterus,  and  a  distinct  mass  was  felt  in  the  left  side.  This  ab- 
sorbed without  operation.  Peterson  says,  "I  know  that  the  last  two  were 
attacks  of  extra-uterine  fecundation.  I  cannot  state  positively  about  the 
first  attack,  but  I  am  very  sure  that  the  right  tube  was  affected  at  that 
time."  Whereas  operation  did  not  verify  the  findings  in  each  instance, 
considerable  stress  may  be  put  upon  its  authenticity,  since  she  came 
under  the  observation  of  a  careful  observer  and  the  symptoms  of  ec- 
topic pregnancy  were  clearly  marked. 

The  case  of  Brettauer  is  still  clearer.  Brettauer  says,  "The  patient 
referred  to  was  operated  upon  at  Beth  Israel  Hospital,  New  York,  in 
April  1904,  when,  according  to  the  records  of  that  institution,  the  left 
appendage  was  removed  for  extra-uterine  gestation.  In  February,  1905, 
she  was  admitted  to  the  Mt.  Sinai  Hospital,  and  came  under  my  care. 
She  had  missed  two  periods,  had  had  a  sudden  attack  of  pain,  and  irregu- 
lar uterine  bleeding.  Physical  examination  showed  a  large  hematocele, 
occupying  practically  the  entire  pelvis.  On  top  and  toward  the  left  was 
the  uterus.  A  posterior  vaginal  section  was  done  on  February  25,  and 
a  large  amount  of  fluid  and  coagulated  blood  were  removed.  There  is  a 
reference  in  the  history  to  a  fetus,  but  I  am  not  positive  about  it  and 
would  rather  leave  this  point  in  doubt.  Convalescence  was  uneventful. 
On  February  2,  1908  (three  years  later),  she  was  again  admitted  to  my 
service  with  a  history  of  having  missed  two  periods,  severe  abdominal 
pain,  and  a  fainting  spell  two  weeks  before.  Examination  showed  a 
retroflexed  uterus  low  down  in  the  pelvis.  To  the  left  of  the  uterus  was 
a  large  irregular  mass,  the  size  of  an  orange,  and  closely  adherent  to  it, 
and  to  the  right  a  second  somewhat  larger  mass  was  felt,  movable,  soft, 
and  tender.  On  opening  the  abdomen  the  mass  on  the  left  was  found  to 
be  a  fibroid  attached  to  the  uterus  by  a  broad  pedicle.  The  one  on  the 
right  consisted  of  a  large,  somewhat  organized  blood  clot,  adherent  to  the 
intestine,  with  one  half  still  within  the  widely  dilated  end  of  the  tube. 
Two  thirds  of  the  tube  was  amputated  and  the  rest  fixed  to  the  ovary. 
No  left  appendage  was  present.  After  removing  the  fibroid  the  uterus 
was  suspended  and  the  patient  discharged  after  an  undisturbed  con- 
valescence.    Microscopical  examination  showed  decidua  and  chorionic 

villi." 

Twin  Ectopic  Pregnancy. — Twin  tubal  pregnancy  may  be  uni- 
lateral, where  one  tube  contains  two  embryos,  or  bilateral,  where  both 
tubes  are  simultaneously  pregnant.  To  these  classifications  McCalla  8 
would  add  two  others,  multiple  tubal  pregnancy,  one  tube  containing  one 
embryo  and  the  other  two  or  more,  and  multiple  tubal  pregnancy,  one 


RECURRENT  EXTRA-UTERINE  PREGNANCY        105 

tube  containing  no  embryo  and  the  pregnant  tube  containing  three  or 
more. 

Both  unilateral  and  bilateral  twin  tubal  pregnancies  are  rare,  though 
some  fifty  cases  are  recorded  in  the  literature.  Many  of  these  are  not 
properly  twin  pregnancies,  since  it  is  frequently  noted  in  the  case  reports 
that  considerable  intervals  of  time,  sometimes  years,  have  elapsed  be- 
tween the  development  of  the  pregnancies.  Indeed  a  lithopedion  in  one 
tube,  and  a  recently  ruptured  gestation  sac  in  the  other,  have  been  reported 
as  twin  tubal  pregnancy.  Obviously,  these  are  cases  of  repeated  ectopic, 
and  in  no  sense  multiple  f  etations.  McDonald  and  Krieger  9  point  out  the 
difficulties  and  the  criteria  of  diagnosis  of  multiple  tubal  pregnancies. 

Blood  clot  in  a  tube,  when  there  is  a  fetus  in  the  opposite  tube,  is  no 
proof  that  gestation  has  occurred  in  both  tubes.  Even  the  presence  of 
decidual  cells  in  one  tube,  while  the  other  tube  has  a  gestation,  is  no  proof 
that  pregnancy  has  occurred  in  the  tube  with  decidual  cells  and  no  fetus, 
since  definite  decidua  has  been  found  in  the  uninvolved  tube  by  Kramer  10 
and  by  Haultain.11  McDonald  and  Krieger  hold  that,  to  definitely  diag- 
nose tubal  pregnancy,  a  fetus  or  chorionic  villi  must  be  found.  They 
have  collected  25  proved  Cases  of  double  tubal  pregnancy  from  the  litera- 
ture. 

Proust  and  Buquet 12  reviewed  the  literature  of  bilateral  simultaneous 
tubal  pregnancy  up  to  19 14  and,  after  examining  into  the  merits  of  82 
cases,  accepted  as  genuine  33,  which  they  believe  to  be  true  instances  of 
simultaneous  bilateral  tubal  gestation.  Lockyer  13  adds  one  case  of  his 
own  and  accepts  the  case  of  Max  Cheval,  thus  bringing  the  total  up  to  35, 
which  Lockyer  thinks  is  too  high. 

The  diagnosis  of  simultaneity  is  somewhat  difficult  to  reach.  When 
the  embryos  are  both  preserved  and  of  the  same  size,  the  diagnosis  is 
assured.  Lockyer  thinks  that,  to  establish  definitely  the  diagnosis  of  si- 
multaneity, "it  should  be  based  upon  thorough  macro-  and  microscopical 
investigation,  and  the  pathological  findings  should  harmonize  with  the 
clinical  history  of  a  single  impregnation  ending  in  a  typical  crisis  or  in 
two  crises,  more  or  less  contemporaneous;  and  in  some  cases  it  will  be 
possible  to  make  out  that  the  pain  is  bilateral  in  a  single  attack.  When 
the  onus  of  proof  lies  on  the  histological  findings,  the  question  of  simul- 
taneity is  based  on  the  character  of  the  villi,  i.e.,  on  their  relative  size, 
development,  and  staining  qualities.  The  villi  in  one  tube  should  so 
closely  correspond  in  all  their  features  to  the  villi  in  the  tube  opposite,  that 
the  sections  might  be  interchanged  without  detection." 

A  characteristic  case  of  unilateral  twin  tubal  pregnancy  is  that  of 
Pool  and  Robin,14  in  which  a  woman  of  27  gave  the  usual  history  of  tubal 


io6 


EXTRA-UTERINE  PREGNANCY 


pregnancy,  and  on  laparotomy  there  was  found  a  ruptured  ampullar 
pregnancy  of  the  left  tube.  There  were  two  fetuses  attached  by  separate 
cords  to  one  placenta  at  the  outer  part  of  the  tube.  The  fetuses  were 
of  the  same  size  and  development,  their  vertex-coccygeal  measurement  be- 
ing 3.3  centimeters.    (Fig.  52.) 


Fig.  52. — Twin  Ectopic  Pregnancy.    From  Pool. 

Triplet  tubal  pregnancy  has  been  recorded  by  Sanger  15  and  Krusen.16 
In  Krusen's  case  a  woman  of  34  had  a  history  of  one  full  term  pregnancy, 
followed  by  five  miscarriages,  again  followed  by  a  full  term  pregnancy. 
After  one  of  the  miscarriages  she  had  suffered  an  illness  apparently  due 
to  pelvic  infection.  After  a  period  of  amenorrhea  lasting  six  weeks, 
the  patient  developed  acute  violent  pelvic  pain  and  other  evidences  point- 
ing to  the  rupture  of  a  tubal  pregnancy.  On  operation  there  was  found 
much  blood  in  the  abdomen,  a  ruptured  and  fragmented  right  tube  con- 


RECURRENT  EXTRA-UTERINE  PREGNANCY        107 

taining  three  fetuses.  The  left  tube  was  the  seat  of  an  old  salpingitis. 
The  patient  was  in  desperate  condition,  succumbing  to  peritonitis  three 
days  later.  The  three  fetuses  were  in  the  second  month  of  gestation, 
were   of   the  same   size,   and  were   apparently  normal   in   all   respects. 

(Fig.  53-) 

Triplet  tubal  pregnancy  is  also  recorded  by  Diament,17  who  found 
the  signs  of  ectopic  gestation  present  in  a  woman  who  had  previously 
borne  two  children.  On  operation  there  was  found  a  tubal  pregnancy, 
and  after  freeing  the  adhesions  and  clots  around  the  ampulla  of  the 
right  tube,  three  embryos,  each  almost  three  centimeters  long,  were  found 
in  Douglas'  cul  de  sac,  having  been  aborted  from  the  right  tube. 


Fig.  53. — Triplet  Ectopic  Pregnancy.    From  Krusen. 

Bilateral  twin  tubal  pregnancy  offers  some  interesting  problems  in 
ovulation.  It  is  impossible  to  imagine  bilateral  tubal  pregnancy  result- 
ing from  the  development  of  twins  from  one  ovum — i.e.,  the  homologous 
or  monochorionic  variety.  Furthermore,  admitting  that  such  twins  are 
dichorionic  ova,  should  both  the  ova  arise  from  the  same  graafian  fol- 
licle, one  must  reach  the  distal  tube  either  by  external  or  internal  migra- 
tion. Or  it  may  be  possible  that  all  tubal  twins  are  the  result  of  the  simul- 
taneous impregnation  of  ova  from  each  of  the  ovaries — a  very  rare  con- 
dition, as  shown  by  the  great  infrequency  with  which  recently  ruptured 
graafian  follicles  are  found  in  both  ovaries  simultaneously. 

When  triple  tubal  pregnancies  are  considered,  twins  in  one  tube  and 
a  single  embryo  in  the  other,  the  case  becomes  more  and  more  involved. 
In  the  present  light  of  biological  knowledge  concerning  ovulation,  the 
whole  subject  may  be  well  closed  with  the  words  of  Ballantyne,  writing 


io8  EXTRA-UTERINE  PREGNANCY 

upon  a  similarly  involved  theme,  "Let  us  leave  this  subject:  it  is  clear 
that  it  is  obscure ;  this  alone  is  clear." 

Combined  Intra-  and  Extra-Uterine  Pregnancy. — The  fact  that 
ectopic  pregnancy  may  exist  coincidently  with  normal  intra-uterine  gesta- 
tion is  well  shown  by  many  recorded  cases. 

In  discussing  the  subject,  it  is  understood  that,  by  combined  preg- 
nancy is  meant  the  presence  of  a  fetus  in  the  uterus  and  one  of  approxi- 
mately the  same  period  of  development  in  the  tube.  Those  cases  of  old, 
long  since  terminated  tubal  pregnancies,  lithopedion,  etc.,  in  connection 
with  an  intra-uterine  fetus,  will  not  be  considered. 

Bichat18  reviewed  the  older  literature,  reporting  48  collected  cases, 
and  adding  one  of  his  own.  In  15  of  Bichat's  cases  a  tumor  other  than 
the  gravid  uterus  was  recognized,  and  occasionally  fetal  parts  and  a  fetal 
heart  were  detected  in  the  tumor.  Rupture  of  the  extra-uterine  sac  oc- 
curred 13  times,  once  5  days  after  the  birth  of  the  intra-uterine  fetus  at 
term.  In  15  cases  the  intra-uterine  ovum  was  expelled  prematurely, 
and  in  12  cases  both  pregnancies  continued  uninterrupted  to  term. 

An  interesting  feature  of  this  complicated  pregnancy  is  that,  in  com- 
mon with  other  acute  pelvic  and  abdominal  lesions,  the  tubal  pregnancy 
may  be  excised  with  safety,  the  intra-uterine  gestation  continuing  to 
term.  Such  a  case  is  recorded  by  Farrar,  in  which  rupture  of  the  tube 
occurred  near  the  uterus  at  the  second  month  of  pregnancy.  The  patient 
was  operated  on  while  almost  pulseless,  but  made  a  good  recovery,  and 
the  intra-uterine  pregnancy  continued  to  term. 

Simpson  19  divides  these  cases  into  four  groups,  as  follows : 

1.  The  woman  becomes  pregnant  while  carrying  the  dead  products 
of  an  ectopic  gestation. 

2.  The  ectopic  and  intra-uterine  products  are  both  living  at  the  same 
time.    Such  cases  are  naturally  subdivided  into  three  groups  : 

(a)  Ectopic  gestation  precedes  the  uterine. 

(b)  Ectopic  conception  follows  the  uterine. 

(c)  Ectopic  and  uterine  conception  occur  coincidentally. 

Class  1  includes  all  the  cases  of  lithopedion,  and  the  end  products 
of  tubal  gestation,  in  which  the  woman  later  becomes  normally  pregnant. 
Obviously  such  cases  are  in  no  sense  combined  pregnancy. 

Class  2  (a),  where  the  ectopic  gestation  precedes  the  intra-uterine, 
are  rare  instances.  Simpson  in  1904  found  only  three  examples  re- 
corded. 

Class  2  (b)  includes  the  cases  in  which  uterine  pregnancy  precedes 
the  tubal  conception.  None  of  the  recorded  cases  has  withstood  the  test 
of  critical  analysis. 


RECURRENT  EXTRA-UTERINE  PREGNANCY  109 

Class  2  (c)  includes  those  cases  in  which  the  clinical  course  indicates 
fecundation  of  the  two  ova  at  or  very  near  the  same  time,  and  in  this 
group  will  be  found  the  bulk  of  the  cases  of  combined  pregnancy. 

(Note:  Simpson's  article  contains  a  full  bibliography  of  combined 
pregnancy  to  1904.) 

Complicated  Extra-Uterine  Pregnancy. — Ectopic  gestation  may 
complicate  or  may  be  complicated  by  the  simultaneous  existence  of  any 
form  of  disease  process.  Any  attempt  to  consider  possible  coincident 
disease  and  the  interrelation  between  the  ectopic  pregnancy  and  the 
added  pathological  condition  would  lead  to  a  profitless  narration  of  case 
records,  interesting  indeed,  but  in  no  sense  usable  either  from  a  clinical 
or  a  purely  theoretical  standpoint. 

For  a  clear  understanding  of  the  subject,  though,  there  are  to  be 
discussed  certain  relationships  which  extra-uterine  pregnancy  bears  to 
other  clinical  entities,  since  these  relations  are  frequently  met  with. 

First,  the  coincident  existence  of  ectopic  gestation  and  tumors  of  the 
pelvic  organs.  It  may  well  be  held  that  such  relation  is  more  than  co- 
incident, since  the  kinking  and  constriction  of  the  tube,  produced  some- 
times by  a  neoplasm  of  a  neighboring  organ,  has  been  given  as  one  im- 
portant causal  factor  in  the  etiology  of  tubal  gestation. 

Tubal  Pregnancy  and  Fibroid  Tumors  of  the  Uterus. — In  an 
analysis  of  934  cases  of  myoma  of  the  uterus,  Cullen  20  found  six  cases  of 
tubal  pregnancy,  all  of  which  had  been  ruptured.  In  four  of  the  cases 
the  symptoms  attributable  to  the  myoma  completely  overshadowed  those 
of  the  tubal  pregnancy.  Consequently  the  surgeon  was  totally  unaware 
of  the  condition  until  the  abdomen  was  opened.  Ovarian  cysts  may 
complicate  ectopic  pregnancy  and  render  the  diagnosis  most  confusing. 
They  also  bear  an  etiological  relationship  to  the  condition  by  pressure 
upon  the  tube  or  by  angulating  their  structures  by  means  of  bands  of 
adhesions.  A  typical  case  of  this  sort  is  reported  in  an  earlier  chapter 
of  this  book  (page  24). 

Abdominal  Inflammatory  Disease  is  an  infrequent  accompani- 
ment of  extra-uterine  pregnancy.  An  interesting  case  of  appendicitis, 
in  combination  with  an  unruptured  tubal  pregnancy,  is  that  of  Vaughn.21 
"A  colored  girl  fifteen  years  old  was  admitted  to  Georgetown  University 
Hospital,  Nov.  27,  191 1,  suffering  with  severe  pain  in  the  abdomen. 
For  two  or  three  years,  she  says,  she  had  suffered  with  abdominal  pain, 
coming  on  at  irregular  times,  worse  in  the  right  side  in  the  region  of  the 
appendix.  Has  had  several  attacks  this  year,  sometimes  accompanied 
by  vomiting.  The  attacks  would  usually  subside  in  two  or  three  days. 
Menstruation,  she  says,  is  usually  regular  and  free  from  pain  and  lasts 


no  EXTRA-UTERINE  PREGNANCY 

five  days.  Last  menstruation  was  Nov.  6  and  lasted  only  four  days. 
The  last  attack  of  pain  came  on  Nov.  2.7 ,  with  griping  pain  in  the  ab- 
domen all  over,  but  worse  on  the  right  side,  with  nausea.  Examination 
next  day:  pulse  80,  temperature  990,  right  side  of  abdomen  tense  but 
not  tender  or  swollen.  Diagnosis :  catarrhal  appendicitis.  Operation 
advised  and  accepted.  Gridiron  incision  on  the  right  side  permitted  the 
delivery  of  the  appendix,  which  was  two  and  a  half  inches  long,  slightly 
swollen  and  congested,  and  bent  on  itself  at  an  acute  angle,  owing  to  the 
peculiar  attachment  of  the  meso-appendix.  It  was  removed  and  the 
pelvic  organs  were  examined  by  palpation.  The  uterus  could  be  felt, 
but  the  right  ovary  could  not  be  recognized.  In  its  place  was  a  smooth 
mass,  giving  the  sensation  of  an  adherent  cyst.  While  palpating,  the 
mass  suddenly  ruptured  and  about  an  ounce  of  dark  blood  clots  es- 
caped, followed  by  a  small  quantity  of  red  blood,  which  soon  ceased.  Two 
of  the  clots  resembled  membrane  and  were  saved  for  further  examina- 
tion. Under  the  microscope  chorionic  villi  were  clearly  seen,  but  the 
embryo  was  not  found.     The  patient  recovered  without  incident." 

The  Toxemias  of  Pregnancy  are  sometimes  noted  in  connection 
with  ectopic  gestation  and,  when  present,  tend  rather  to  clear  up  a  doubt- 
ful diagnosis.  The  pernicious  vomiting  of  early  pregnancy  is  rarely  met 
with,  although  a  moderate  degree  of  nausea  and  vomiting  is  not  uncom- 
mon. 

Eclampsia  at  times  complicates  secondary  abdominal  pregnancy  at 
or  near  term.  The  disease  is  in  no  sense  different  in  its  manifestations, 
whether  the  pregnancy  be  intra-  or  extra-uterine,  the  important  feature 
being  the  necessity  for  abdominal  delivery  in  every  case,  if  the  fetus  be 
extra-uterine,  a  necessity  which  naturally  adds  somewhat  to  the  gravity 
of  the  condition. 

An  interesting  case  of  this  sort  is  contributed  by  Prof.  E.  P.  Davis, 
in  a  personal  communication.  He  says,  "Some  years  ago  I  was  asked 
to  give  a  clinic  at  Harrisburg  and  the  case  selected  for  me  was  as  fol- 
lows :  Primipara,  aged  about  30,  previous  history  negative.  Pregnancy 
had  proceeded  apparently  normally  until  between  the  seventh  and  eighth 
month,  when,  after  albuminuria  of  a  week  or  ten  days,  the  patient  had 
several  eclamptic  convulsions.  She  recovered  from  this  and,  although  she 
had  some  pains,  labor  did  not  occur.  After  her  recovery,  the  abdomen 
grew  smaller  and  fetal  movements  could  not  be  felt,  nor  could  heart 
sounds  be  heard.  Her  general  health  became  good,  but  an  abdominal 
tumor  remained.  On  examination  of  the  patient  there  was  a  central  ab- 
dominal tumor  closely  connected  with  the  uterus  or  part  of  it.  Bimanual 
examination  gave  the  phenomena  usually  seen  in  fibroid  tumors  of  the 


RECURRENT  EXTRA-UTERINE  PREGNANCY        in 

uterus  or  abdominal  pregnancy  with  retained  fetus.  This  diagnosis  was 
given  to  the  physicians  present  at  the  clinic,  and  the  abdomen  was  opened. 
A  dead  fetus  of  about  eight  months  was  in  the  abdominal  cavity,  its  sac 
attached  to  the  upper  portion  of  the  uterus.  The  fetus  was  not  macerated, 
but  the  amniotic  liquid  had  absorbed.  The  placenta  was  attached  to  the 
right  broad  ligament,  the  fetus  was  removed,  the  cord  tied  at  the  placenta 
and  the  greater  part  removed,  the  membranes  stitched  to  the  lower  por- 
tion of  the  abdominal  incision,  and  the  cavity  packed  with  gauze.  The 
attending  physician  maintained  drainage,  the  patient  ultimately  making 
a  good  recovery." 

Much  time  might  be  devoted  to  a  consideration  of  the  coincidence  of 
extra-uterine  pregnancy  and  various  disease  processes  from  the  diagnos- 
tic standpoint,  but  such  relationship  may  occur  in  so  many  different 
phases,  that  a  discussion  of  this  subject  could  not  result  in  more  than  an 
endless  series  of  isolated  case  reports  of  no  especial  value  in  a  categorical 
presentation  of  the  subject,  as  is  contemplated  here. 

Unique  Forms  of  Ectopic  Pregnancy. — Cervical  pregnancy  is 
the  condition  which  results  when  the  ovum  imbeds  itself  in  the  cervix 
uteri  and  there  develops.  It  is  doubtful  whether  such  an  implantation 
site  should  be  classified  as  a  variety  of  placenta  previa,  or  whether  it 
belongs  in  the  category  of  ectopic  gestation.  Inasmuch  as  the  cervical 
canal  is  not  morphologically  identical  with  the  uterine  cavity,  it  seems 
proper  to  include  pregnancies  in  this  area  among  the  varieties  of  ectopic 
gestation. 

The  criteria  of  cervical  pregnancy  according  to  Rubin22  are:  (i) 
There  must  be  cervical  glands  opposite  placental  attachment.  (2)  This 
attachment  of  placenta  to  cervix  must  be  intimate.  (3)  The  whole  or  a 
portion  of  the  placenta  must  be  situated  either  below  the  entrance  of  the 
uterine  vessels  or  below  the  peritoneal  reflection  of  the  anterior  and  pos- 
terior surface  of  the  uterus.  (4)  Fetal  elements  must  not  be  present  in 
the  corpus  uteri. 

Cervical  pregnancy  is  very  rare,  only  a  few  cases  being  reported  in 
the  literature.  It  may  be  primary,  when  imbedding  takes  place  originally 
in  the  cervical  walls,  or  secondary,  when  a  normally  imbedded  ovum  be- 
comes detached  and  reimplants  itself  in  the  cervix.  The  cervix  does  not 
usually  participate  in  decidua  formation,  nor  is  this  necessary  for  the 
development  of  an  ovum,  as  shown  by  the  pathology  of  tubal  and  ovarian 
pregnancy.  The  terminations  of  cervical  pregnancy  are  either  abortion, 
or  more  rarely  rupture.  In  this  latter  case  the  rupture  may  take  place 
in  the  infravaginal  cervix,  into  the  vagina  or  at  the  union  of  the  peritoneal 
folds  around  the  lower  margin  of  the  uterus,  the  hemorrhage  thus  being 


112 


EXTRA-UTERINE  PREGNANCY 


Fig. 


54. — Cervical     Pregnancy     with      Rupture 
into  Abdomen.    From   Rubin. 


intraperitoneal.  Cervical  pregnancy  usually  terminates  within  the  first 
three  months,  though  the  fetus  may  develop  in  the  uterine  cavity,  the 
placenta  remaining  cervical.  Rubin  reports  a  case  in  which  intraperito- 
neal rupture  of  a  cervical  pregnancy  took  place,  with  the  signs  of  intra- 
abdominal hemorrhage. 
On  operation  there  was 
removed  a  uterus  hav- 
ing the  size  of  a  preg- 
nant organ  at  two  and  a 
half  months.  A  fetus  23I/2 
centimeters  long  was  in 
the  uterine  cavity.  On  ex- 
amination, the  placental 
attachment  was  below  the 
insertion  of  the  uterine 
vessels  and  the  lowermost 
points  of  reflection  of  the 
uterine  serosa. 

Ectopic  pregnancy  in 
the  gland  spaces  of  an 
adenomyoma  of  the  uterus  has  been  reported  by  Doderlein  and  Herzog.23 
"There  was  present  an  adenomyoma  in  the  left  tubal  angle  or  below  it. 
The  tumor  contained 
glandular  spaces,  which 
were  probably  derived, 
not  from  any  embryonic 
inclusions  originating 

from  the  wolffian  body, 
but  from  the  uterine  mu- 
cosa. The  gland  spaces 
may  have  been  present  in 
the  tumor  from  the  very 
beginning  or  they  may 
have  entered  into  its  sub- 
stance at  a  somewhat  la- 
ter period  in  consequence 

oi  inflammatory  processes.  Evidently  there  was  a  connection  between 
the  uterine  mucosa  and  the  gland  spaces  of  the  tumor.  A  fertilized 
ovum,  by.  some  unexplainable  coincidence,  got  into  the  gland  spaces  of 
the  tumor  and  there  developed.  A  fairly  typical,  though  quite  irregular, 
decidua  was  formed  and  the  growing  ovum  stimulated  the  tumor  to 


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Fig.    55. — Cervical    Pregnancy.      From    Rubin. 


RECURRENT  EXTRA-UTERINE  PREGNANCY        113 

rapid  growth  and  created  for  itself  a  cavity  to  accommodate  the  placenta. 
Pregnancy  was  interrupted,  the  embryo  died,  and  was  expelled  in  frag- 
ments. The  latter  were  forced  through  the  glandular  canal  connecting 
the  tumor  cavity  with  the  uterine  body." 

Hemorrhage  from  Ovary  or  Tube  Simulating  Ruptured  Ectopic 
Pregnancy. — Hemorrhage  from  the  ovary  or  from  the  tube  may 
occur  entirely  independent  of  the  element  of  pregnancy,  and  the  symp- 
tom complex,  as  well  as  the  operative  findings,  may  so  closely  simulate  a 
ruptured  ectopic  gestation  sac,  that  undoubtedly  many  such  cases  have 
been  misinterpreted  and  have  been  recorded  as  instances  of  the  latter 
condition,  when  painstaking  microscopical  examination  of  the  tissues 
would  have  revealed  the  true  state  of  affairs.  Hemorrhage  from  the 
ovary  may  originate  in  a  graafian  follicle,  or  in  the  ovarian  stroma. 

Rupture  of  an  apparently  normal  graafian  follicle  may  lead  to  serious 
hemorrhage.  Two  such  cases  are  reported  by  Primrose,24  in  which  the 
excessive  bleeding  apparently  followed  some  increase  in  intra-abdominal 
pressure  from  muscular  effort.  One  of  his  cases  followed  the  lifting 
of  a  heavy  weight,  while  the  second  was  superinduced  by  the  vomiting 
attendant  upon  an  acute  appendicitis. 

According  to  Bovee,25  ovarian  hematoma  is  a  condition  that  has 
long  been  recognized.  Peuch,  in  1858,  declared  ovarian  apoplexy  ac- 
tually exists  and  may  cause  death;  it  may  form  a  hematoma  and  may 
or  may  not  be  absorbed.  The  condition  has  been  so  often  encountered, 
as  also  have  its,  at  times  dangerous,  associated  conditions,  that  none 
should  regard  it  as  a  myth  or  even  a  curiosity.  Hemorrhage  in  the  ovary 
occurs  normally  as  it  does  in  normal  parturition.  It  may  occur  in  graa- 
fian follicles  or  in  an  ovarian  cyst  when  the  venous  circulation  of  its  ped- 
icle is  obstructed  by  twisting  of,  or  pressure  exerted  on,  that  structure.  It 
may  occur  in  the  stroma,  constituting  a  true  hematoma.  It  may  occur 
in  toxic  conditions,  causing  several  accumulations  of  variable  size,  like 
those  found  in  the  kidney  and  other  organs  and  which  are  noted  in 
autopsies  on  patients  dying  of  typhoid  fever  or  other  conditions  having 
a  local  septic  origin,  such  as  puerperal  sepsis  or  perforated  gastric  or 
duodenal  ulcer  (Wilson).  Ovarian  pregnancy  is  a  rare  cause.  Hemor- 
rhage into  the  stroma  or  into  a  follicle  may  occur  in  the  newly  born  in- 
fant, fully  developed,  as  in  the  case  of  Schultze,  in  quite  young  girls  at 
or  near  the  first  menstrual  period,  and  in  early  adult  life  or  during  the 
child  bearing  period,  and  may  be  accounted  for  in  the  noninfected  cases 
by  undue  hyperemia,  notable  during  the  first  few  menstrual  periods. 
Great  sexual  excitement  is  believed  to  be  quite  a  common  cause.  Wilson 
states  there  is  one  case  on  record  of  a  woman  who  died  from  shock  on 


ii4  EXTRA-UTERINE  PREGNANCY 

the  eve  of  her  marriage  as  the  result  of  a  profuse  intraperitoneal  hemor- 
rhage from  a  ruptured  corpus  luteum.  In  early  menstrual  life  profuse 
and  prolonged  uterine  hemorrhage  is  far  more  common,  and  it  is 
urged  by  some  writers  that  this  is  from  the  irritation  caused  by  con- 
tinued bleeding  from  the  ruptured  graafian  follicle. 

Scanzoni  reports  a  case  of  a  girl  dying  from  such  profuse  follicular 
hemorrhage  during  menstruation.  At  autopsy  he  found  three  liters  of 
blood  in  the  peritoneal  cavity.  A  considerable  number  of  cases  have  ap- 
peared in  literature,  like  that  of  Fordyce,  in  which  women,  especially 
girls,  exposed  to  cold  and  wet  immediately  preceding,  or  very  early  in,  a 
menstrual  period,  have  been  the  victims  of  ovarian  hemorrhage  so  great 
in  amount  as  to  demand  immediate  abdominal  section.  In  the  inflamma- 
tory cases  a  quite  well  defined  sclerosis  of  the  ovary  has  taken  place, 
giving  rise  to  excessive  formation  of  connective  tissue  in  the  ovary  with 
fatty  degeneration  of  the  blood  vessels,  which  rupture  easily.  It  is  prob- 
able in  such  a  changed  state,  that  expulsion  of  the  ovum  is  retarded  and 
the  consequence,  prolonged  congestion,  provokes  hemorrhages  into  both 
the  follicle  and  the  stroma.  When  rupture  of  the  bleeding  ovary  occurs, 
whether  naturally  from  a  graafian  follicle  or  pathologically  from  overdis- 
tention  due  to  blood  accumulated  in  its  stroma,  free  exit  is  given  to  escap- 
ing blood  and  hemorrhage  is  encouraged,  more  especially  during  ovular 
hyperemia.  The  rapidity  of  the  flow  of  blood  varies  from  a  few  drops 
to  such  large  quantities  as  have  been  mentioned. 

Schroder  states  that  rupture  of  a  graafian  follicle  may  in  exceptional 
cases  be  followed  by  so  profuse  a  hemorrhage  that  it  can  ( i )  prove  fatal; 
(2)  cause  peritonitis  which  may  terminate  fatally;  (3)  produce  an  en- 
capsulated blood  clot  in  the  peritoneal  cavity;  or  (4)  produce  a  retro- 
uterine hematocele.   (Bovee.) 

Tubal  hemorrhage  is  not  so  well  understood  as  is  that  from  the  ovary. 
While  ectopic  pregnancy  is  the  active  agent  in  its  production  in  a  pre- 
ponderating proportion  of  cases,  yet  no  one  can  doubt  its  occurrence 
quite  frequently  in  postinfectional  conditions,  and  in  some  instances  re- 
ports have  distinctly  stated  that  neither  inflammation  nor  pregnancy  was 
evident.  In  the  writer's  judgment,  the  cases  in  which  pregnancy, 
the  result  of  infection,  and  traumatism,  are  all  absent,  must  be  ex- 
tremely rare.  The  relation  of  ovarian  and  tubal  hemorrhage  to  intra- 
peritoneal hematocele  needs  no  elucidation  from  the  writer. 

The  difference  between  hemorrhage  limited  to  the  ovarian  stroma 
and  that  in  which  there  is  peritoneal  inundation  from  the  same  cause, 
appears  to  depend  merely  upon  the  amount  of  the  bleeding  and  not  upon 
any  difference  in  mechanism. 


RECURRENT  EXTRA-UTERINE  PREGNANCY  115 

Bovee  feels  that  in  the  presence  of  hemorrhage  of  tubal  or  ovarian 
origin,  where  there  is  not  positive  clinical  evidence  of  pregnancy  as  evi- 
denced by  the  finding  of  a  fetus  or  chorionic  villi,  one  is  not  justified  in 
making  a  diagnosis  of  extra-uterine  pregnancy,  unless  proven  by  mi- 
croscopical examination,  and  he  supports  his  contention  by  a  record  of 
29  cases  of  supposed  ectopic  gestation  with  free  hemorrhage  from  ovary 
and  tube,  in  which  microscopical  evidence  supported  the  diagnosis  in  17. 
This  rather  extreme  view  is  counterbalanced  by  the  work  of  Caturani,26 
who  examined  100  specimens  of  suspected  extra-uterine  pregnancy, 
finding  positive  evidences  of  this  lesion  in  85,  only  15  proving  negative. 


Fig.  56. — A   Hematoma  of  the  Tube,   Not  Associated  with    Pregnancy  of  any 
Variety,  but   Strongly  Simulating  Tubal  Gestation.     (Author's  case). 

The  pathology  of  ovarian  hemorrhage,  when  it  takes  place  into  the 
stroma,  is  usually  that  of  preexisting  oophoritis,  and  peri-oophoritis,  with 
the  development  of  an  excess  of  connective  tissue,  which  impedes  the  rup- 
ture of  the  graafian  follicle  and  causes  the  formation  of  a  retention  cyst. 
This  is  followed  by  a  slow  sclerosis  with  fatty  degeneration  of  the  stromal 
vessels,  and  these,  being  subjected  to  strain  during  the  ovarian  congestion 
incident  to  ovulation  or  intense  sexual  excitement,  are  unequal  to  resist 
the  increased  blood  pressure  and  rupture,  the  blood  escaping  either  into 
the  parenchyma  of  the  ovary  or  into  a  follicular  cyst. 

Follicular  hemorrhage  may  result  from  the  rupture  of  a  normal 
well  developed  graafian  follicle,  as  a  result  of  sudden  increase  of  intra- 
abdominal pressure,  or  it  may  occur  in  follicles  undergoing  retrogression, 


n6  EXTRA-UTERINE  PREGNANCY 

and  in  which  the  unfertilized  ovum  has  died,  with  the  formation  of  a 
small  retention  cyst,  having  well  marked  vascular  supply.  These  forms 
of  ovarian  and  tubal  hemorrhage  possess  no  pathognomonic  features  and 
a  diagnosis  of  the  true  origin  of  the  hemorrhage  is  usually  not  possible 
until  microscopic  examination  clears  up  the  situation.  The  onset  of  the 
attack  and  the  symptomatology  is  strikingly  similar  to  that  of  a  ruptured 
ectopic  gestation. 

The  writer  has  had  no  personal  experience  with  ovarian  hemorrhage, 
but  one  typical  case  of  bleeding  from  a  tube,  with  evidence  of  pregnancy, 
may  be  cited.  A  spinster  of  30  noted  a  sharp  attack  of  left  pelvic  pain 
one  year  before  admission.  The  pain  gradually  subsided,  to  recur  at  the 
menstrual  period  with  increasing  severity  each  month.  There  was  pain 
on  defecation  and  a  slight  loss  of  weight.  On  examination  a  distinct 
mass  was  palpated  in  the  left  vaginal  vault.  Operation  revealed  a  greatly 
distended  left  tube,  the  enlargement  measuring  five  centimeters  in  diame- 
ter, being  globular  in  character  and  occupying  the  middle  third  of  the 
tube.  There  was  a  small,  organized  pelvic  hematocele.  The  right  tube 
and  both  ovaries  were  normal.  The  left  tube  was  excised,  the  patient 
making  an  uneventful  recovery.  On  section  of  the  tube,  the  mass  was 
found  to  consist  of  organized  blood  clot.  Microscopically  there  was  con- 
siderable erosion  of  the  mucosa  by  hemorrhage  into  the  muscular  coat, 
but  no  evidence  whatever  of  decidual  formation,  villi  or  syncytial  cells. 
(Fig.  56.) 

LITERATURE 

1.  Wassmer.     Monschr.  f.  Gebh.  u.  Gyn.     1903.     17:88. 

2.  Smith,  R.  R.     Repeated  Ectopic  Pregnancy.    Am.  Jr.  Obst.     191 1. 

64:401. 

3.  Giles,  A.  E.    A  Study  of  the  After  Results  of  Abdominal  Operations 

on  the  Pelvic  Organs.    Jr.  Obst.  Gyn.  Brit.  Emp.     1910.     17:153. 

4.  Essen-Moller.     L'obstetrique.     Paris,  191 1.     4:249.     Quoted  by 

Smith. 

5.  Prochowntk.     Wien.  Med.  Woch.     1895.     14:1266,  also  Munch. 

Med.  Woch.     1900.    64. 

6.  Engstrom.     Mitth.  a.  d.  Gyn.  Klin,  in  Helsingfors.     p.  327. 

7.  Smith,  R.  R.       Ectopic  Pregnancy  and  Repeated   Ectopic  Preg- 

nancies.   Surg.  Gyn.  Obst.     1914.     18:684. 

8.  McCalla,  S.  P.     Twin  Tubal  Pregnancy  and  Bilateral  Tubal  Preg- 

nancy.   Surg.  Gyn.  Obst.     1909.    8:248. 

9.  McDonald,  E.,  and  Krieger,  W.  C.     Multiple  Ectopic  Pregnancy. 

Jr.  Am.  Med.  A.     1913.    60:1766. 


RECURRENT  EXTRA-UTERINE  PREGNANCY  117 

10.  Kramer.     Arch.  f.  Gyn.     1903.     68:57. 

n.  Haultain.    Jr.  Obst.  Gyn.  Brit.  Emp.     1906.    9:6. 

12.  Proust  et  Buquet.     Rev.  de  gyn.  et  de  chir.  abd.     1914.     23  -.353. 

13.  Lockyer,  C.    Simultaneous  Bilateral  Tubal  Pregnancy.     Proc.  Roy. 

Soc.  Med.     1916-17.     10:88. 

14.  Pool,  E.  H.,  and  Robin,  F.     Unilateral  Twin  Tubal  Gestation. 

Am.  Jr.  Obst.     1910.     61  :6o6. 

15.  Sanger.     tJber  ein  Fall  von  Ektopischer  Drillings-Schwangerschaft. 

Centrbl.  f.  Gyn.     1893.     P-  :48- 

16.  Krusen,  W.    Triple  Ectopic  Gestation.    Am.  Med.  Jr.    1902.    p.  18. 

17.  Diament.     Centrbl.  f.  Gyn.     1914.     No.  3. 

18.  Bichat.    Rev.  de  gyn.  et  de  chir.  abd.    1903.    7:412. 

19.  Simpson,  F.  F.     A  Consideration  of  Combined  Ectopic  and  Intra- 

uterine Pregnancy.     Am.  Jr.  Obst.     1904.     49 :333- 

20.  Cullen,  T.  S.     Myomata  of  the  Uterus.     Philadelphia,  1909.     p. 

342. 

21.  Vaughn,  G.  T.    Ectopic  Pregnancy  Complicating  Appendicitis.  Am. 

Jr.  Obst.     1912.    66:829. 

22.  Rubin,  I.  C.     Cervical  Pregnancy.     Surg.  Gyn.  Obst.     191 1.     13: 

625. 
2^.  Doderlein,  T.  O.,  and  Herzog,  M.    Surg.  Gyn.  Obst.     1913.     16: 
14. 

24.  Primrose,  A.     Hemorrhage  into  the  Peritoneal  Cavity  Caused  by 

Accidental  Rupture  of  the  Ovary.     Ann.  Surg.     1912.     p.  125. 

25.  Bovee,  J.  W.     The  Conflict  of  Clinical  and  Microscopical  Evidence 

in  the  Diagnosis  of  Tubal  and  Ovarian  Pregnancies.     Am.  Jr. 
Obst.     1918.    76:370. 

26.  Caturani,  M.     To  What  Extent  Must  We  Depend  Upon  the  Mi- 

croscopical Examination  to   Support  the   Clinical  Diagnosis   of 
Ectopic  Pregnancy?     Am.  Jr.  Obst.     1919.     79:716. 


CHAPTER  VI 

THE    DIAGNOSIS    AND    SYMPTOMATOLOGY    OF    EXTRA-UTERINE 

PREGNANCY 

The  Previous  History— Absolute  Sterility— Preexisting  Pelvic  Disease— The  General 
Health  and  the  Medical  History  of  the  Patient— The  Findings  on  General  Ex- 
amination of  the  Patient— Blood  Pressure— The  Diagnosis  of  Ectopic  Pregnancy— 
The  Diagnosis  of  Long  Existing  and  Untreated  Ectopic  Gestation— The  Diagnosis 
of  Ectopic  Pregnancy,  Other  Than  Tubal — Ovarian  Pregnancy — Abdominal  Preg- 
nancy— The  Diagnosis  of  Lithopedion  and  Adipocere — The  Diagnosis  of  Com- 
plicated Ectopic  Gestation — The  Differential  Diagnosis  of  Ectopic  Pregnancy — 
Differentiation  of  Ectopic  Gestation  from  Acute  Salpingitis — The  Histological 
Diagnosis  of  Extra-Uterine  Pregnancy. 

A  discussion  of  the  diagnosis  and  symptomatology  of  ectopic  preg- 
nancy opens  a  large  and  somewhat  confused  subject,  the  various  phases 
of  which  must  be  grouped  and  the  groups  accurately  correlated  before 
any  definitive  statements  are  made. 

The  fact  that  pregnancy  of  some  type  exists  must  first  be  con- 
firmed, after  which  a  localization  of  the  imbedded  ovum  may  be  at- 
tempted, first  as  to  whether  it  be  intra-uterine  or  extra-uterine  and,  if 
the  latter,  which  structures  are  invaded  by  the  aberrantly  situated  ovum. 
Diagnostic  signs  must  also  be  differentiated  into  those  present  before 
rupture  or  tubal  abortion  has  taken  place,  those  noted  immediately  after 
such  rupture  or  tubal  abortion,  and  those  apparent  in  later  cases,  where 
fetus  and  appendages,  an  old  encapsulated  blood  clot,  or  both  are  present 
in  the  abdominal  cavity. 

A  reader  of  text  books  upon  gynecology  and  obstetrics  must  inevit- 
ably reach  the  conclusion  that  the  diagnosis  of  unruptured  ectopic  preg- 
nancy should  be  made  in  the  majority  of  cases,  and  that  recognition  of 
the  condition  after  rupture  or  tubal  abortion  is  made  simple  by  the  de- 
velopment of  a  train  of  signs  and  symptoms  unvarying  in  their  course 
and  apparent  at  a  glance  to  a  trained  observer. 

This  happy  situation,  unfortunately,  does  not  too  often  occur.  In- 
deed, even  in  the  hands  of  expert  gynecologists,  the  diagnosis  of  unrup- 
tured extra-uterine  gestation  is  more  noteworthy  by  the  high  percentage 
of  error  than  by  the  frequency  with  which  correct  conclusions  are  at- 
tained. 

Furthermore,  with  respect  to  the  cases  in  which  rupture  or  tubal  abor- 

118 


DIAGNOSIS  AND  SYMPTOMATOLOGY  119 

tion  has  actually  taken  place,  the  clinical  picture  is  often  so  obscure  and 
the  physical  signs  so  parallel  other  acute  abdominal  lesions  of  widely 
divergent  character,  that  even  here  experienced  men  often  cannot  form 
a  clear  conception  as  to  the  condition  existent  within  the  peritoneal  cav- 
ity. Obviously,  cases  presenting  the  classical  phenomena  of  extra-uterine 
pregnancy,  either  before  or  after  rupture,  are  commonly  seen,  and  here 
the  diagnosis  presents  no  difficulties ;  but  in  studying  a  large  series  of  case 
records,  the  writer  believes  it  to  be  almost  a  rule  that  the  signs  and  symp- 
toms, which,  if  taken  separately,  would  suggest  ectopic  gestation,  lead 
to  most  conflicting  conclusions  when  grouped,  as  they  must  be.  The 
logical  method  of  solution  of  the  difficult  problem  of  diagnosis  is  to  cate- 
gorically arrange  the  whole  matter  of  ectopic  gestation  into  its  natural 
divisions,  consider  each  division  as  a  clinical  entity,  and  then  allow  for 
biological  variation  of  case  from  case  and  for  the  confusion  of  diagnostic 
evidence  caused  by  the  overlap  of  one  phase  of  the  condition  over  an- 
other. 

The  natural  anatomicopathological  groups  into  which  ectopic  gesta- 
tion falls  are : 

1.  The  existence  of  tubal  pregnancy,  without  any  leakage  of  blood 
into  the  abdominal  cavity  whatever. 

2.  Tubal  pregnancy  with  beginning  tubal  abortion  or  a  minute  rup- 
ture, permitting  a  minute  quantity  of  free  blood  to  come  in  contact  with 
peritoneal  surfaces. 

3.  Tubal  pregnancy  with  frank  rupture  of  the  sac  or  tubal  abortion. 

4.  Late  abdominal  lesions  caused  by  a  preexisting  tubal  pregnancy, 
where  rupture  or  tubal  abortion  has  been  unrecognized  or  at  least  not 
surgically  treated — hematocele,  lithopedion  formation,  old  traumatic  sal- 
pingitis and  the  like. 

5.  Ectopic  pregnancy  other  than  tubal — ovarian,  abdominal  and  cor- 
nual. 

The  foregoing  completes  the  groups  in  which  a  direct  diagnosis  is 
necessary.  The  question  of  differential  diagnosis  also  readily  falls  into 
certain  great  divisions,  as  follows  : 

1.  Differential  diagnosis  of  ectopic  pregnancy  from  intra-uterine 
pregnancy,  with  or  without  threatened  abortion. 

2.  Differential  diagnosis  of  ectopic  pregnancy  from  lesions  of  the 
reproductive  tract  not  associated  with  pregnancy  in  any  sense,  but  caus- 
ing hemorrhage  into  the  pelvic  peritoneum — as  ovarian  apoplexy,  unex- 
plained hemorrhage  of  tubal  origin,  etc. 

3.  Differential  diagnosis  of  ectopic  pregnancy  from  other  acute 
lesions  of  the  abdomen. 


120  EXTRA-UTERINE  PREGNANCY 

The  first  group,  that  in  which  extra-uterine  pregnancy  exists,  but 
the  ovum  and  its  envelopes  are  as  yet  entirely  contained  within  the  tube, 
is  the  one  wherein  lie  those  baffling  obscurities  and  generally  indefinite 
signs,  whose  very  presence  renders  the  diagnosis  difficult. 

A  review  of  the  facts  as  presented  will  prove  the  contention  that 
the  diagnosis  of  ectopic  gestation,  before  the  death  and  beginning  sepa- 
ration of  the  ovum,  or  before  rupture  of  the  tubal  wall  has  occurred,  is 
a  matter  of  so  much  doubt  that  its  successful  performance  is  almost  to 
be  considered  a  fortunate  incident.  The  history  is  to  some  degree  sig- 
nificant when  taken  as  a  whole.  There  will  usually  have  been  a  period 
of  amenorrhea,  or  at  least  a  delayed  period,  in  a  woman  usually  regular. 
In  the  preruptured  stage,  there  is  scarcely,  or  never,  any  uterine  bleeding. 
The  associated  history  of  a  previous  pelvic  operation  or  attack  of  pelvic 
pain,  due  presumably  to  a  low  grade  salpingitis,  and  the  fact  that  the 
patient  is  the  mother  of  a  small  family,  or  one  child  sterility,  is  of  some 
presumptive  value.  There  may  be  present  the  concomitant  symptoms 
and  signs  of  early  pregnancy,  though  regrettably,  these  are  usually  con- 
spicuous by  their  absence. 

Vaginally  there  may  be  detected  a  slight  degree  of  softening  of  the 
cervix,  and  perhaps  a  minor  enlargement  of  the  uterus.  The  tube  will 
rarely  be  palpable.  There  is  little  or  no  pelvic  pain,  no  leukocytosis,  and 
no  change  in  the  urine. 

Since  the  evidence  of  any  pathological  condition  is  so  slight  and  vague, 
it  will  readily  be  seen  that  in  this  stage  of  the  progress  of  ectopic  gesta- 
tion the  patient  rarely  finds  it  necessary  to  consult  a  physician.  The  de- 
layed or  missed  menstrual  period  is  considered  by  the  woman  as  evi- 
dence of  a  possible  pregnancy.  The  subjective  symptoms,  when  present, 
serve  to  confirm  the  opinion,  and  if  a  mild,  dull  pain  develops  in  one  or 
the  other  iliac  fossa,  it  is  ascribed  to  some  ovarian  condition  incidental 
to  the  pregnancy.  Only  when  the  marked  symptoms  referable  to  rup- 
ture or  tubal  abortion  make  their  appearance,  does  the  woman  become 
alarmed  and  invoke  the  aid  of  her  physician,  who,  all  too  often,  fails 
to  be  impressed  by  the  significance  of  the  grouped  facts  in  the  history 
of  the  patient,  and  considers  the  case  one  of  intra-uterine  pregnancy  with 
some  irritability  of  the  uterus  and  possibly  a  threatened  abortion.  Fur- 
thermore, as  Hunner1  points  out,  there  are  undoubtedly  many  women 
with  extra-uterine  pregnancy  who  never  even  consult  a  physician  and 
never  have  serious  difficulties.  The  changes  in  the  circulation  may  early 
rob  the  fetus  of  its  blood  supply,  resulting  in  death  and  absorption. 

The  signs  of  early  pregnancy,  the  breast  changes,  pigmentation,  etc., 
are  usually  conspicuous  by  their  absence.     Upon  vaginal  examination, 


DIAGNOSIS  AND  SYMPTOMATOLOGY  121 

the  enlarged  and  swollen  fallopian  tubes  may  be  palpated,  but  only  in  a 
very  small  proportion  of  the  cases.  Boldt  2  says  "I  have  never  palpated  a 
tubal  pregnancy  prior  to  the  occurrence  of  symptoms  due  to  the  pathologi- 
cal implantation  of  the  ovum,  except  in  one  instance — a  double  tubal 
gestation."  He  further  well  says  that,  though  the  statement  not  in- 
frequently occurs  in  literature,  that  the  diagnosis  of  uninterrupted  ectopic 
gestation  has  been  made  by  palpation,  if  the  cases  are  carefully  analyzed, 
it  will  almost  invariably  be  found  that  bleeding  into  the  tube  had  taken 
place,  showing  that  the  process  of  interruption  of  the  gestation  had 
been  begun. 

It  must  be  remembered  that  the  fallopian  tube,  when  not  the  seat  of 
inflammatory  exudate,  or  when  it  has  not  been  fixed  in  position  by  ad- 
hesions, is  of  a  consistency  about  like  that  of  intestinal  coils,  and  its  pal- 
pation through  the  vaginal  vault  is  a  matter  of  the  utmost  difficulty  and 
uncertainty.  Early  tubal  pregnancy,  before  separation  of  the  ovum  and 
bleeding  into  the  tube  takes  place,  does  not  appreciably  alter  the  con- 
sistency of  the  tubal  wall,  nor  does  the  tube  increase  markedly  in  size 
as  a  result  of  the  presence  of  the  imbedded  ovum.  Palpation  of  the  af- 
fected tube  is  accordingly  a  matter  of  extreme  technical  difficulty  and 
uncertainty. 

Ectopic  pregnancy,  before  bleeding  takes  place  into  the  tubal  wall 
or  the  peritoneal  cavity,  may  be  said  to  be  a  lesion  incipient  in  all  respects, 
provoking  little  or  no  reaction  upon  the  physiology  of  the  patient,  and 
presenting  only  the  most  elusive  details  upon  which  a  diagnosis  may  be 
based.  In  consequence,  the  diagnosis  is  made  only  in  isolated  cases,  and 
then  usually  by  accident. 

The  cases  included  in  group  two  of  the  classification  for  diagnostic 
purposes  are  those  in  which  beginning  tubal  abortion  or  a  minute  rupture 
of  the  tube  permits  a  small  quantity  of  free  blood  to  come  into  contact 
with  peritoneal  surfaces,  death  of  the  embryo,  or  beginning  separation  of 
the  decidua  going  on  meanwhile.  It  is  among  the  patients  in  this  group 
that  certain  signs  occur,  which  should  clearly  define  the  pathological  proc- 
ess, and  here  it  is  that  a  correct  diagnosis  may  and  should  be  made  in 
the  vast  majority  of  cases,  provided  the  details  of  the  history  and  the 
physical  findings  be  carefully  surveyed. 

Speaking  broadly,  the  evidences  upon  which  a  correct  conclusion  may 
be  based  are,  first  of  all,  the  history;  then  the  behavior  of  the  men- 
strual flow;  third,  the  indefinite  signs  of  a  pregnancy;  fourth,  the  pres- 
ence of  pelvic  pain,  even  though  this  be  slight  in  character;  and,  lastly, 
the  elicitation  of  a  tender  mass  in  one  or  the  other  vaginal  fornix  upon 


122  EXTRA-UTERINE  PREGNANCY 

vaginal  examination,  together  with  the  presence  of  certain  gestational  al- 
terations in  the  uterus  itself. 

The  history  is  by  all  odds  the  most  important  single  feature  in  reach- 
ing a  diagnosis,  but  in  order  to  logically  prove  the  importance  of  this  fac- 
tor, the  other  diagnostic  features  will  be  first  considered,  and  then  re- 
viewed to  demonstrate  the  importance  of  the  history  in  correlating  all 
the  facts  in  the  case. 

In  regard  to  the  behavior  of  the  menstrual  flow,  with  few  exceptions, 
there  will  have  occurred  a  period  of  amenorrhea,  varying  from 'the  miss- 
ing of  one  or  more  periods  with  no  bleeding  whatever  to  a  simple  delay 
of  one  or  two  weeks,  followed  by  a  slight  irregular  "spotting"  or  a  more 
frank  bleeding,  differing,  according  to  the  statement  of  various  observers, 
from  normal  menstrual  discharge,  in  that  the  blood  is  darker  and  more 
viscid. 

In  Farrar's3  analysis  the  menstrual  period  was  overdue  in  34  per 
cent. 

Foskett  4  says  that  the  amenorrhea  may  be  a  relatively  unimportant 
factor  in  the  history,  since  only  a  little  over  50  per  cent  of  his  patients 
had  missed  a  period.  He  adds,  however,  that  in  general  there  is  a  his- 
tory of  irregularity.  Crudely  put,  the  history  usually  involves  the  state- 
ment that  the  patient  was  a  few  days  or  a  week  overdue,  with  some  spot- 
ting or  bleeding  before  the  expected  arrival  of  the  next  regular  period. 

Bandler  5  says  that  in  early  diagnosis  the  two  symptoms  of  greatest 
value  are  atypical  menstruation,  or  metrorrhagia  and  pain.  The  "atypi- 
cal menstruation  of  ectopic  gestation"  is  an  expression  used  by  Bandler 
to  direct  attention  to  the  appearance  of  blood  generally  out  of  rhythm 
with  the  normal  menstrual  cycle  of  the  individual.  The  amount  of  blood 
lost  may  be  very  much  greater  or  very  much  less  than  the  usual  men- 
strual flow  of  the  patient.  It  may  be  continuous  or  it  may  appear  with 
interruptions.  It  may  be  darker,  lighter  or  more  brownish  than  the 
usual  menstruation. 

In  MacKenzie's  6  careful  study  there  was  some  degree  of  amenorrhea 
in  75  per  cent  of  the  145  cases,  and  of  the  remaining  25  per  cent,  or 
39  cases,  thirteen  were  not  subjected  to  operation  and  therefore  not 
proven  to  be  ectopic  pregnancy,  and  nine  were  found,  on  operation,  to  be 
cases  of  pelvic  hematocele,  which  might  or  might  not  have  had  their 
origin  in  an  extra-uterine  pregnancy. 

Howard  C.  Taylor7  states  that  in  his  series  of  46  cases,  81  per  cent 
gave  a  history  of  irregularity  in  the  menstrual  bleeding. 

Rongy  8  found  that  in  75  cases  the  menstrual  period  was  delayed  in 


DIAGNOSIS  AND  SYMPTOMATOLOGY  123 

53,  or  71  per  cent.  The  average  period  of  amenorrhea  was  about  eight 
weeks. 

Summary:  Analyzing  the  various  statistics  of  a  group  of  modern, 
trained  observers,  and  averaging  their  opinions,  it  may  be  stated  as  a  defi- 
nite fact  that  mentrual  irregularity,  varying  from  the  delay  of  an  ex- 
pected period  for  a  few  days,  to  profuse  metrorrhagia,  is  a  characteristic 
of  at  least  three  fourths  of  the  case  histories  in  tubal  pregnancy.  The  ir- 
regular bleeding,  which  so  uniformly  occurs  in  the  presence  of  ectopic 
pregnancy,  possesses  certain  definite  characteristics.  So  long  as  the  life 
and  growth  of  the  ovum  progresses  without  interference,  there  is  no 
uterine  bleeding,  and  the  development  of  this  sign  invariably  predicates 
death  of  the  embryo,  or  at  least  its  beginning  separation  from  the  false 
decidua  into  which  it  has  imbedded. 

This  feature  of  the  hemorrhage  is  excellently  put  by  Taylor,9  who 
says,  "The  hemorrhage  is  usually  due  to  some  separation  of  decidual 
membrane  from  the  interior  of  the  uterus  and  is  moreover  a  sign  that  the 
vitality  of  the  pregnancy  is  endangered  or  destroyed.  So  long  as  the 
pregnancy,  although  out  of  place,  is  growing  and  uninjured,  there  is,  as 
a  rule,  no  uterine  bleeding.  External  hemorrhage,  therefore,  is  not  so 
much  a  sign  of  extra-uterine  pregnancy  as  of  some  secondary  disease  or 
injury,  which  has  affected  the  pregnancy;  but  as  the  great  majority  of 
cases  suffer  accidental  changes  during  the  earlier  months,  it  becomes  a 
sign  of  great  importance. 

The  bleeding  may  occur  without  coincident  pelvic  pain,  but  such  cases 
are  in  the  minority.  For  example,  in  Oastler's  10  series  of  106  cases, 
bleeding  was  closely  associated  with  attacks  of  pain  in  all  but  eleven.  In 
these  the  flow  began  some  considerable  time  after  the  pain.  Uterine 
hemorrhage  was  certainly  absent  in  two  cases,  and  bleeding  continued  in- 
termittently for  five  months  in  two  cases. 

In  Farrar's  3  series  bleeding  was  present  in  67.4  per  cent  of  the  cases. 
In  this  group  bleeding  occurred  in  five  instances  without  pain,  and  Farrar 
thinks  it  probable  that  the  contractions  of  the  tube  are  not  sufficiently 
forceful  to  cause  severe  pain  until  the  supreme  effort  to  rupture  the  tubal 
wall  takes  place. 

In  Polak's  n  large  series  of  227  cases  222  of  the  women  presented 
some  menstrual  anomaly,  as  a  period  of  amenorrhea,  prolongation  of  the 
normal  period,  anomalous  character  of  the  bloody  discharge,  or  an  an- 
ticipated period,  followed  by  an  intermittent  or  continuous  metrorrhagia. 
According  to  Polak,  this  vaginal  discharge,  which,  is  irregular  in  occur- 
rence and  amount,  has  presented  definite  characteristics;  it  is  brownish 


124  EXTRA-UTERINE  PREGNANCY 

red  blood  mixed  with  mucus  which  does  not  clot,  and  its  quantity  is  in- 
creased from  time  to  time,  coincident  with  the  painful  paroxysms. 

The  bleeding  of  extra-uterine  pregnancy  is  rarely  large  in  amount, 
and  herein  lies  an  important  point  in  the  differential  diagnosis  of  extra- 
from  intra-uterine  pregnancy  with  threatened  abortion.  Hemorrhage 
from  the  uterus  to  the  point  of  producing  any  demonstrable  evidence  of 
an  acute  anemia  almost  never  occurs,  and  where  a  very  profuse  vaginal 
hemorrhage  is  associated  with  definite  signs  of  an  ectopic  gestation,  the 
case  should  at  once  arouse  the  suspicion  that  coincident  extra-uterine  and 
intra-uterine  pregnancy  are  present. 

Taking  the  combined  experience  of  investigators  along  the  foregoing 
lines,  it  may  be  said  in  summing  up,  that  metrorrhagia  of  some  degree 
is  a  very  strong  affirmative  symptom  of  the  existence  of  ectopic  preg- 
nancy, the  strength  of  the  sign  as  a  factor  in  diagnosis  increasing  as  the 
coordinating  facts  are  developed  in  the  study  of  the  individual  case. 

Concomitant  Signs  of  Pregnancy. — The  third  point  in  the 
diagnosis  of  the  group  of  prehemorrhagic  cases  is  the  determination  of 
the  existence  of  pregnancy  of  some  variety.  The  signs  of  pregnancy  dur- 
ing the  early  weeks,  both  objective  and  subjective,  may  be  detailed  as : 

Amenorrhea, 

Morning  nausea  and  vomiting, 

Pain  and  tingling  in  the  breasts,  with  the  appearance  of  colostrum, 

Increased  pigmentation  in  various  skin  areas, 

Softening  of  the  cervix, 

Enlargement  of  the  uterus, 

Cyanosis  of  the  vaginal  mucosa, 

Increased  anteflexion  of  the  uterus, 

Frequency  of  urination, 

The  Abderhalden  reaction. 

In  general,  it  may  be  said  that  these  signs  and  symptoms  are  almost 
invariably  less  marked  when  the  fecundated  ovum  is  aberrantly  situated; 
only  in  rare  instances  are  many  of  the  signs  present  in  any  given  case  of 
extra-uterine  gestation,  and  in  the  majority  of  instances  they  are  so  in- 
tangible as  to  be  almost  negligible  in  lending  weight  to  a  positive  diag- 
nosis of  tubal  pregnancy.  On  the  other  hand,  if  the  usual  evidences  of 
early  normal  gestation  be  demonstrable  in  marked  degree,  they  strongly 
negative  the  diagnosis  of  extra-uterine  pregnancy  and  greatly  increase 
the  probability  of  the  gestation  sac  being  normally  implanted  within  the 
uterine  cavity. 


DIAGNOSIS  AND  SYMPTOMATOLOGY  125 

Cessation  of  the  menstrual  flow  and  its  characteristic  irregular  return 
have  already  been  discussed. 

The  morning  nausea  seems  to  be  present  in  some  degree,  although; 
in  studying  the  analysis  of  large  series  of  case  histories  in  the  literature, 
the  point  has  received  but  little  attention.  Granting  that  the  gastro- 
intestinal phenomena  represent  some  reflex  irritation  of  sensory  nerves, 
due  to  the  presence  of  a  new  protein  element  in  the  metabolism,  it  is  nat- 
ural that  this  sign  should  accompany  the  development  of  an  embryo, 
whatever  its  situation.  If,  however,  the  nausea  be  due  to  a  direct  re- 
ferred irritation  of  the  uterine  nerve  supply  itself,  as  is  held  by  a  large 
number  of  obstetricians,  there  would  seem  to  be  but  little  reason  for  the 
occurrence  of  this  symptom  complex  in  extra-uterine  gestation. 

The  fact  remains  that,  in  about  one  half  of  the  cases  careful  amnesis 
will  bring  out  the  fact  that  morning  nausea  and  occasional  vomiting  has 
been  noted.  This  must  not  be  confounded  with  the  vomiting  which  so 
usually  develops  with  beginning  rupture,  as  a  result  of  the  irritation  of 
the  peritoneum  by  the  presence  of  free  blood. 

As  a  diagnostic  factor,  this  morning  nausea  and  vomiting  is  of  no 
positive  importance,  but  must  be  regarded  as  rather  of  negative  value. 
Pain  and  colostrum  in  the  breasts  are  usually  present  in  some  degree.  In 
Farrar's  one  hundred  cases  pain  and  colostrum  were  present  in  eighteen, 
18  per  cent.  In  Frank's  12  analysis  he  states  that  "pain  and  the  presence 
of  colostrum  in  the  breasts  were  repeatedly  noted  in  the  histories."  Band- 
ler  thinks  it  uncommon.  Taylor  found  enlarged  and  tender  breasts  in 
44  per  cent  of  his  cases. 

The  subject  may  be  dismissed  with  the  comment  that  breast  changes 
are  unimportant  in  so  far  as  a  diagnosis  of  ectopic  pregnancy  is  con- 
cerned, but  that  their  presence  contributes  to  the  knowledge  that  the 
patient  is  pregnant  in  some  wise. 

Increased  pigmentation,  the  appearance  of  the  linea  nigra,  and  the 
darkened  mammary  areola,  are  signs  so  frequently  absent  or  but  vaguely 
present,  even  in  intra-uterine  pregnancy,  that  they  must,  of  necessity, 
play  but  a  small  role  in  differentiating  extra-  from  intra-uterine  gesta- 
tion. 

The  local  signs  of  pregnancy,  when  present,  and  they  usually  are 
present  in  some  degree,  may  easily  confuse  the  diagnosis.  Softening  o£ 
the  cervix  and  increase  in  the  size  of  the  uterus  are  the  rule  in  these  cases. 

In  Farrar's  one  hundred  cases,  the  cervix  was  softened  in  twelve  and 
the  fundus  enlarged  in  32,  44  per  cent,  thus  showing  change  in  the  size 
and  consistency  of  the  uterus. 

Inasmuch  as  there  is  always  a  decidua  formed  in  the  uterus  when 


126  EXTRA-UTERINE  PREGNANCY 

an"  ovum  is  impregnated,  enlargement  of  the  organ,  even  though  small 
in  degree,  is  always  to  be  expected  in  cases  of  ectopic  pregnancy. 

The  uterus  is  usually  sharply  anteflexed,  as  pointed  out  by  Oastler,10 
who  regards  the  anteflexion  as  an  important  fact  in  differentiating  be- 
tween ectopic  pregnancy  and  old  tubal  disease,  since  in  the  latter  the 
adhesions  formed  tend  to  pull  back  the  uterus  in  retroposition,  whereas 
in  ectopic  gestation  the  pathological  condition  does  not  exist  long  enough 
to  cause  any  adhesions. 

Frequency  of  urination  is  noted  in  something  less  than  one  half  of 
the  case  records  examined,  though  in  one  of  the  writer's  cases  it  was  the 
paramount  symptom  and  the  one  which  brought  the  patient  to  her  physi- 
cian for  relief.  It  is  not  a  sign  of  any  diagnostic  import,  except  that  it 
may  be  regarded  as  slight  affirmative  evidence  of  the  existence  of  preg- 
nancy. 

The  Abderhalden  reaction  is  mentioned  merely  to  emphasize  the  fact 
that,  as  a  diagnostic  factor,  it  is  of  only  the  slightest  value.  When  posi- 
tive, it  may  be  regarded  as  one  more  point  in  favor  of  a  diagnosis  of  preg- 
nancy, but  the  absence  of  the  reaction  by  no  means  negatives  the  possi- 
bility of  pregnancy  having  occurred,  nor  does  it  in  any  way  assist  in  the 
diagnostic  separation  of  extra-  from  intra-uterine  gestation. 

Pain  in  the  pelvis,  usually  occurring  in  a  more  or  less  definite  cycle, 
is  the  most  important  and  constant  sign  of  ectopic  pregnancy,  more  note- 
worthy after  rupture  or  tubal  abortion  has  taken  place,  but  a  most  signifi- 
cant symptom,  even  before  any  blood  has  escaped  from  the  tubes. 

In  the  analysis  of  Wynne  13  pain  was  the  predominant  symptom  in 
254  of  303  cases,  or  84  per  cent.  In  Farrar's  3  series  of  186  cases,  pain 
with  or  without  bleeding  was  present  in  96.6  per  cent. 

Out  of  Williams'  series  of  147  cases,  pain  was  present  as  the  chief 
symptom  in  no,  or  80  per  cent. 

Ninety-five  per  cent  of  Frank's  cases  gave  pain  as  an  important 
symptom. 

Such  instances  may  be  multiplied  indefinitely,  though  in  using  these 
series  of  case. records  as  indicative  of  the  predominance  of  pain  as  a 
symptom,  it  must  be  remembered  that  the  cases  are  not  usually  classified 
as  to  the  degree  of  rupture  or  the  extent  to  which  traumatism  has  ad- 
vanced within  the  peritoneal  cavity. 

The  etiology  of  the  pain  is  threefold.  First,  when  the  ovum  dies  or 
separation  of  the  embryonal  envelopes  from  their  abnormal  decidua  be- 
gins, the  ovum  becomes  a  foreign  body  and  the  tube  makes  efforts  to 
expel  it,  via  the  fimbriated  extremity,  by  means  of  vigorous  peristaltic 
action  on  the  part  of  its  muscular  coat.     The  clinical  expression  of  this 


DIAGNOSIS  AND  SYMPTOMATOLOGY  127 

tubal  muscular  contraction  is  colicky  pain,  noted  first  in  the  region  of  the 
diseased  tubes  and  later  transmitted  to  the  uterus,  which  in  time  begins 
to  undergo  contraction. 

Second,  under  the  circumstances  present  there  is  usually  a  variable 
amount  of  bleeding  into  the  peritoneal  cavity,  and  generalized  dull,  lower 
abdominal  pain  becomes  a  noteworthy  symptom,  as  a  result  of  the  sen- 
sory reaction  of  the  peritoneum  to  the  irritative  effect  of  blood  in  direct 
contact  with  it. 

Third,  as  the  blood  accumulates  within  the  pelvis,  it  gravitates  to  the 
most  dependent  portion  and  forms  a  clot  or  masses  of  clots  in  the  cul  de 
sac  of  Douglas,  with  the  development  of  pain  especially  noted  during 
defecation,  as  the  fecal  masses  impinge  upon  the  blood  clot  and  force 
it  against  the  sensitive  peritoneal  surface  and  the  uterosacral  ligaments. 
The  importance  of  this  symptom  of  painful  defecation  has  been  empha- 
sized by  Polak,  who  notes  that  on  several  occasions,  it  has  been  the  first 
point,  when  taken  in  conjunction  with  a  skipped  or  delayed  menstrual 
period,  to  direct  his  attention  to  the  possibility  of  ectopic  pregnancy. 

Lastly,  if  an  effusion  of  blood  takes  place  into  the  tubal  wall,  or 
between  the  folds  of  the  broad  ligament,  then  will  follow  a  dull  throb- 
bing, pressure  pain  as  the  increasing  amount  of  blood  distends  the  tis- 
sues. 

The  types  of  pain  which  have  just  been  described  may  be  present  in 
any  combination  in  any  case;  but  in  order  to  elicit  this  phase  of  the 
symptomatology  from  the  patient,  it  is  obvious  that  very  careful  and 
patient  questioning  is  necessary,  and  further,  in  developing  the  history, 
great  care  must  be  taken  that  too  much  insistence  be  not  laid  upon  any 
one  symptom,  lest  the  woman  be  influenced  by  the  suggestion  and  describe 
sensations  she  did  not  in  reality  experience. 

The  Previous  History. — The  older  writers  upon  extra-uterine 
pregnancy  laid  great  stress  upon  a  history  of  sterility,  a  long  period  of 
marital  life  since  the  birth  of  the  last  child,  evidence  of  preexisting  pelvic 
inflammation,  and  a  record  of  previous  consecutive  gynecological  opera- 
tions. Let  us  examine  the  very  careful  analysis  of  later  writers  who 
have  observed  long  series  of  cases,  and  ascertain  in  how  far  their  early 
opinions  are  correct. 

Parry,  in  his  classical  work,  says  that  "ectopic  conception  occurs 
most  frequently  in  women  showing  previous  inaptitude  for  conception," 
and  these  oft  quoted  words  have  been  the  keynote  upon  which  later 
writers  based  their  statements. 

Absolute  Sterility. — In  Farrar's  series  of  186  cases,  31,  or  16.6 
per  cent,  were  absolutely  sterile,  but  of  these  31  cases,  15  had  been  mar- 


128  EXTRA-UTERINE  PREGNANCY 

ried  less  than  five  years,  and  therefore,  in  the  light  of  present  day  ideas 
with  respect  to  the  prevention  of  conception  among  recently  married 
couples,  it  would  seem,  at  best,  a  matter  of  great  doubt  whether  patients 
of  less  than  five  years  marital  experience  should  properly  be  listed  as  ster- 
ile. Frank  12  analyzes  a  series  of  eighty  cases,  and  in  these,  even  if  the 
short  and  insufficient  period  of  one  year  is  regarded  as  an  arbitrary 
criterion  of  sterility,  only  7.5  per  cent  fall  into  this  class. 

In  Rongy's  series  of  84  cases,  17  patients  had  not  previously  been 
pregnant  (20  per  cent),  but,  as  Rongy  does  not  mention  the  length  of 
time  these  women  had  been  married,  it  is  fair  to  assume  that  a  reason- 
able proportion  had  been  living  under  marital  conditions  for  so  short 
a  time  that  they  were  not  true  cases  of  sterility. 

Foskett4  found  that  27  of  his  117  patients  had  not  previously  been 
pregnant  (21  per  cent).  Here,  too,  however,  the  length  of  time  mar- 
ried is  not  mentioned,  so  that  the  percentage  is  in  all  probability  much 
too  high  to  regard  as  representative  of  the  proportion  of  absolute  steril- 
ity in  the  series. 

Among  Taylor's  9  patients,  there  were  4  cases  of  absolute  sterility  in 
46  patients,  or  a  percentage  of  8.6  per  cent. 

Averaging  the  above  figures,  it  is  found  that  15  per  cent  of  patients 
in  whom  extra-uterine  pregnancy  exists  have  not  previously  been  preg- 
nant, but,  as  has  been  shown,  the  length  of  time  married  is  not  men- 
tioned in  a  number  of  the  statistics,  and  when  it  is  recorded,  this  time  is 
too  short  to  properly  constitute  a  true  pathological  sterility. 

In  the  careful  study  of  MacKenzie  6  there  had  been  no  previous  preg- 
nancy in  23  per  cent  of  the  150  cases  studied,  or  15  per  cent. 

It  is  estimated  that  from  10  to  12  per  cent  of  marriages  among  Cau- 
casians are  sterile,  as  a  result  of  either  male  or  female  disability.  If  to 
this  number  there  be  added  the  marriages  rendered  unfruitful  by  deliber- 
ate intent,  and  such  are  by  no  means  uncommon,  it  will  be  seen  that,  in- 
asmuch as  sterility,  using  the  term  in  its  most  loose  sense,  only  occurs 
in  from  7  to  15  per  cent  of  all  women  suffering  from  ectopic  gestation, 
this  factor,  as  a  casual  lesion,  plays  but  a  minor  role. 

When,  however,  the  comparatively  unfruitful  marriages  are  con- 
sidered, the  so-called  one  child  sterility,  or  those  cases  in  which  the  off- 
spring have  been  limited  either  as  a  result  of  some  pathological  process 
in  husband  or  wife,  or  by  methods  designed  to  prevent  conception,  the 
proportion  of  extra-uterine  gestation  rises  to  a  marked  extent. 

For  example,  MacKenzie  6  found,  in  his  study  of  ectopic  pregnancy, 
that  30  per  cent  of  his  patients  had  borne  but  one  child,  and  26  per  cent 
had  two  previous  pregnancies  recorded.    This  leads  him  to  remark  that 


DIAGNOSIS  AND  SYMPTOMATOLOGY  129 

the  greatest  liability  attaches  to  one  pregnancy,  and  extra-uterine  gesta- 
tion is  more  likely  to  occur  in  the  mother  of  a  small  family,  since  in  80 
per  cent  of  his  cases  there  was  a  history  of  three  or  less  previous  preg- 
nancies. 

Farrar's  series  shows  32.2  per  cent  of  cases  occurring  in  relation  to 
one  child  sterility,  and  in  Rongy's  eighty-four  patients,  forty-six  had  had 
three  or  less  previous  pregnancies,  while  among  Williams'  records  of  121 
histories,  64  patients  were  the  mothers  of  less  than  three  children. 

Summary. — The  conclusion  to  be  reached  in  the  matter  of  sterility 
as  an  etiological  factor  is  that  absolute  sterility  is  an  indefinite  and  un- 
important point  in  the  development  of  the  diagnosis,  while  the  fact  that 
one  or  two  children  have  been  born  over  a  period  of  years,  is  a  diagnostic 
point  of  considerable  value,  when  taken  in  connection  with  the  other 
significant  details  of  the  history  and  physical  examination. 

The  birth  of  many  children  in  rapid  succession  has  been  held  to  be 
a  factor  in  the  etiology  of  ectopic  pregnancy.  Polak  X1  says  that  the 
condition  arises  frequently  among  women  who  are  the  subjects  of 
rapidly  recurring  and  repeated  pregnancies,  as  may  be  found  among  our 
foreign  population,  particularly  the  Jews,  Italians  and  Irish.  This  ob- 
servation is  not  generally  borne  out  by  a  survey  of  other  statistics. 

Only  10  per  cent  of  MacKenzie's  patients  had  borne  five  or  more 
children,  and  2  per  cent  had  borne  seven  or  more.  Frequent  fecundation 
is  not  therefore  to  be  considered  as  important  in  studying  a  case  history. 

The  passage  of  a  considerable  interval  of  time  between  the  last, 
pregnancy  and  the  extra-uterine,  is  usually  regarded  as  significant  in  an 
etiological  sense. 

MacKenzie  found  that  42  per  cent  of  his  cases  occurred  within  two 
years  of  a  previous  pregnancy,  and  59  per  cent  followed  within  5  years 
of  childbirth. 

In  one  hundred  cases  of  Farrar's  68  had  borne  a  child  or  suffered  a 
miscarriage  five  years  or  less  previous  to  the  development  of  the  ectopic 
condition. 

The  average  time  elapsing  in  Williams's  79  cases,  where  the  date  of 
this  preceding  normal  pregnancy  or  miscarriage  was  given,  before  the 
ectopic  gestation  developed,  was  three  years  and  nine  months. 

In  Rongy's  series  the  last  pregnancy  occurred  less  than  five  years 
prior  to  the  ectopic  in  31  of  a  total  of  45  cases. 

If  the  foregoing  figures  be  surveyed,  it  must  be  agreed  that  the 
length  of  the  intergravid  period  is  not  a  constant  nor  valuable  detail  in 
arriving  at  a  diagnosis. 

Pre-existing  Pelvic  Disease  must  of  necessity  be  of  prime  im- 


i3o  EXTRA-UTERINE  PREGNANCY 

portance  as  a  causative  agent;  but  unfortunately,  the  clinical  signs  of  a 
pelvic  lesion  may  be  slight  and  indefinite,  and  a  pathological  condition 
well  able  to  cause  peritubal  adhesions  with  kinking  or  strictures  of  the 
tubal  lumen,  may  have  not  greatly  disturbed  the  patient  during  its  acute 
stage  and,  in  consequence,  is  frequently  forgotten  by  her  when  giving  a 
history  of  past  complaints,  especially  during  the  stress  of  hospital  resi- 
dence with  a  prospective  abdominal  operation  in  view.  Farrar  shows  an 
incidence  of  10  per  cent  of  histories  of  infection.  Oastler's  series  con- 
tained 22  cases  of  pelvic  infection  in  a  total  of  106,  or  20  per  cent. 

It  is  probable  that,  were  it  possible  to  obtain  these  details,  a  very  high 
percentage  of  all  causes  of  ectopic  pregnancy  would  be  found  to  have 
suffered  from  preexisting  pelvic  infection  of  some  type.  As  the  facts  in 
these  relations  cannot  be  obtained,  it  must  suffice  that  a  history  of  previous 
pelvic  disease  is  to  be  considered  a  strong  affirmative  point  in  a  diagnosis 
of  extra-uterine  gestation,  but  the  absence  of  such  history  cannot  be  re- 
garded as  of  any  negative  value. 

Previous  operations  on  pelvic  viscera  or  upon  those  organs  occupying 
the  inferior  portion  of  the  abdominal  cavity,  often  leave  such  alterations 
in  the  normal  anatomy  of  these  parts  as  to  predispose  strongly  to  the 
subsequent  development  of  extra-uterine  pregnancy.  This  feature  of  the 
history,  however,  as  a  diagnostic  point  is  greatly  weakened,  should  the 
patient  have  experienced  a  normal  pregnancy  in  the  interval  between  the 
operative  procedure  and  the  development  of  a  suspected  ectopic  gestation. 

Oastler  found  that  13  of  his  106  cases  had  been  subjected  to  previous 
abdominal  operations;  Farrar,  16  in  186  cases,  including  four  previous 
ectopics;  and  Foskett  found  histories  of  6  women  previously  operated 
upon  in  a  total  of  117  cases. 

Considering  the  comparatively  small  proportion  of  women  who  have 
been  subjected  to  laparotomy,  in  relation  to  the  feminine  population  as 
a  whole,  it  is  clear  that,  inasmuch  as  nearly  9  per  cent  of  a  large  series 
of  cases  of  ectopic  pregnancy  have  had  previous  abdominal  sections 
performed,  this  feature  of  the  history  is  of  prime  importance  as  a  positive 
factor  in  reaching  a  diagnosis,  and  great  stress  should  accordingly  be 
laid  upon  it. 

The  General  Health  and  the  Medical  History  of  the  Patient. — 
In  a  broad  sense,  tendency  to  infectious  diseases,  traumatism,  and  the 
like  seem  to  have  no  etiological  bearing  on  the  development  of  extra- 
uterine pregnancy. 

A  review  of  the  anamnesis,  then,  from  the  "diagnostic  standpoint 
would  lead  to  the  following  conclusions : 


DIAGNOSIS  AND  SYMPTOMATOLOGY  131 

1.  .Previous  general  health,  and  family  history  is  of  no  diagnostic 

value. 

2.  Absolute  sterility  is  not  definitely  associated  with  the  occurrence 

of  ectopic  pregnancy. 

3.  Relative  sterility,  especially  the  one  child  type,  on  the  contrary, 

is  a  significant  point,  and  should  be  regarded  as  moderately 
affirmative. 

4.  The  passage  of  a  considerable  interval  of  time  between  the  last 

intra-uterine  pregnancy  and  the  present  suspected  ectopic  one 
is  unimportant  in  diagnosis,  and  may  be  disregarded. 

5.  A  history  of  preexisting  pelvic  disease  is  of  great  importance 

when  obtainable,  but  the  absence  of  such  history  should  not  be 
an  influence  against  a  positive  diagnosis  of  ectopic  fecunda- 
tion. 

6.  Previous   abdominal  operations   indubitably   render   the  patient 

more  liable  to  aberrant  imbedding  of  the  fecund  ovum. 

The  Findings  on  General  Examination  of  the  Patient. — Where 
a  tubal  pregnancy  is  present,  before  rupture  or  tubal  abortion  has  taken 
place,  the  physical  signs  are  in  general  negative,  as  to  a  diagnosis.  The 
blood  and  urine  usually  show  no  change  referable  to  the  condition,  the 
blood  picture  especially  being  in  striking  contrast  to  that  noted  after 
rupture  has  occurred. 

The  physical  findings  in  cases  of  beginning  rupture  or  tubal  abortion 
in  tubal  pregnancy  are  quite  frequently  definite  enough  to  be  considered 
pathognomonic.  They  consist  of  the  presence  of  a  tender  mass  occupying 
the  site  of  one  or  the  other  tube,  with  or  without  a  doughy  fullness  in  the 
posterior  vaginal  fornix  and  the  palpatory  evidence  of  a  blood  clot  in 
the  cut  de  sac  of  Douglas. 

Farrar's  series  revealed  a  pelvic  mass  or  a  definite  enlargement  of 
adnexa  on  one  side  in  96  of  100  cases,  or  96  per  cent.  Frank  found  a 
palpable  mass  in  one  of  the  fornices  or  in  the  cul  de  sac  in  86  per  cent 
of  his  cases.  The  mass  was  usually  described  as  "boggy,"  and  was 
regularly  tender  on  pressure.  As  a  rule,  vascular  pulsation  over  or  in 
the  neighborhood  of  the  mass  was  exaggerated.  This  sign  of  vascular 
pulsation  has  been  emphasized  by  several  observers,  but  in  the  opinion  of 
the  writer  is  of  but  slight  value,  being  frequently  noted  in  cases  of  normal 
pregnancy,  as  well  as  those  of  acute  or  subacute  salpingitis. 

Among  Oastler's  records  of  106  cases,  pelvic  masses  were  noted  in 
86  per  cent.  The  masses  are  not  usually  large,  nor  are  they  dense  in 
consistency,  but  are  soft  and  not  too  easily  demonstrable.  It  is  note- 
worthy that  the  tenderness  on  vaginal  examination  is  usually  out  of  all 


132  EXTRA-UTERINE  PREGNANCY 

proportion  to  the  size  and  density  of  the  mass  palpated,  and  to  the 
experienced  gynecologist  the  disproportionate  tenderness  is  highly  sug- 
gestive of  the  presence  of  an  ectopic  gestation,  as  against  acute  salpin- 
gitis. Traction  on  the  cervix  or  active  manipulation  of  the  uterus 
greatly  aggravates  the  pain  and  tenderness. 

The  uterus  is  generally  in  anteflexion,  since,  as  pointed  out  by  Oastler, 
the  adhesions  formed  in  inflammatory  conditions  tend  to  pull  back  the 
uterus  in  retroversion,  whereas  in  ectopic  pregnancy  the  pathological 
condition  does  not  exist  long  enough  to  cause  this  position.  Oastler 
found,  in  106  cases,  anteposition  in  87  and  retroversion  in  19. 

Size  of  the  Uterus. — The  uterus,  when  ectopic  pregnancy  exists, 
is  usually  enlarged,  though  the  enlargement  does  not  bear  the  proper 
relation  to  the  duration  of  the  pregnancy,  as  determined  by  the  history, 
being  in  general  less  than  would  be  the  case,  did  intra-uterine  pregnancy 
exist. 

For  practical  purposes,  the  enlargement  of  the  uterine  body  is  of 
but  little  value,  since,  as  most  tubal  pregnancies  are  terminated  by  rupture 
or  tubal  abortion  before  the  tenth  week,  the  uterine  enlargement  is  so 
slight  as  not  to  be  demonstrable,  especially  in  cases  when  previous  preg- 
nancies have  occurred  and  a  relative  increase  in  the  size  of  the  uterus 
is  physiological. 

Cyanosis  of  the  vaginal  mucosa  has  already  been  discussed. 

Hegar's  sign  is  not  to  be  elicited,  no  matter  what  the  size  of  the 
uterus,  and  is  therefore  of  considerable  negative  value  in  determining  a 
diagnosis.  Should  Hegar's  sign  be  present,  together  with  the  other  signs, 
intra-uterine  pregnancy  is  almost  a  certainty,  though  it  may  well  be 
complicated  by  a  coexisting  tubal  gestation. 

The  passage  of  masses  of  decidua  or  complete  decidual  casts  from 
the  uterus  is  of  great  value  positively,  but  of  no  great  negative  im- 
portance, since  the  decidua  may  well  have  been  passed  previous  to  the 
patient's  coming  under  observation.  Should  a  decidual  cast  be  passed, 
it  does  not  offer  definite  proof  of  the  presence  of  extra-uterine  preg- 
nancy, since  such  structures  are  found  sometimes  in  early  intra-uterine 
pregnancy,  with  death  of  the  embryo. 

Microscopical  examination  will  settle  the  diagnosis  in  such  instances, 
the  finding  of  chorionic  villi  in  the  decidual  tissue  establishing  the  diagno- 
sis of  intra-uterine  abortion,  while  the  presence  of  decidual  cells  with- 
out villi  predicates  the  existence  of  extra-uterine  pregnancy  (see  Decidua, 
in  section  on  pathology). 

It  is  most  important  that  extreme  gentleness  be  employed  in  the 
conduct  of  bimanual  examination  in  a  case  of  suspected  ectopic  gestation. 


DIAGNOSIS  AND  SYMPTOMATOLOGY  133 

All  too  often  has  the  tube  been  ruptured  in  the  physician's  office  and  the 
patient  placed  in  deadly  peril  of  her  life,  by  a  neglect  of  this  precaution. 

On  no  account  should  a  uterine  sound  be  used. 

The  abdomen  in  these  cases  is  usually  rigid  to  some  degree,  the 
rigidity  naturally  affecting  more  definitely  the  rectus  muscle  on  the  side 
of  the  affected  tube. 

The  abdomen  is  generally  tender  on  palpation,  though  a  marked 
difference  is  usually  noted  between  the  degree  of  abdominal  tenderness 
and  that  elicited  by  the  vaginal  finger  in  the  course  of  a  bimanual  examina- 
tion. There  is  frequently  present  a  moderate  degree  of  abdominal  dis- 
tention, rarely  excessive.  The  attacks  of  pain  are  accompanied  by 
nausea  and  vomiting  in  about  one  half  the  recorded  cases,  while  at  this 
stage  syncope  is  rare.  In  general,  when  beginning  tubal  abortion  or 
minute  rupture  of  an  ectopic  gestate  sac  has  occurred,  the  condition  of 
the  patient  is  strongly  suggestive  of  an  "acute  abdomen"  of  moderate 
severity,  without  any  localizing  or  pathognomonic  symptoms  to  be  de- 
tected outside  the  genital  tract. 

The  pulse  is  usually  slightly  elevated,  running  between  86  and  92 
in  the  writer's  experience.  The  temperature  is  almost  always  slightly 
elevated,  as  an  expression  of  the  peritoneal  reaction  to  the  presence  of 
free  blood,  and  secondarily  to  the  very  common  development  of  a  mild 
pelvic  peritonitis  about  the  extravasated  blood  and  the  tube  itself.  This 
point  was  well  brought  out  by  Brickner  in  his  study  of  cases  from  Mt. 
Sinai  Hospital. 

The  temperature  is  usually  not  high,  ranging  from  990  to  1020  R, 
rarely  above  the  latter  figure. 

The  blood  picture  reveals  a  commonly  present  leukocytosis  of  low 
degree,  usually  about  10,000  or  12,000,  again  an  expression  of  peritoneal 
irritation  by  extravasated  blood.  The  leukocytosis  in  these  cases  behaves 
in  a  characteristic  manner  which,  when  doubt  exists,  forms  a  valuable 
adjunct  to  the  formulation  of  a  correct  diagnosis. 

If  the  hemorrhage  be  inconsiderable  in  amount,  the  leukocyte  count 
rises  slightly  within  a  few  hours  after  the  bleeding  begins,  while  the 
red  cells  show  no  appreciable  diminution  in  number,  nor  is  the  hemo- 
globin percentage  affected. 

The  leukocytosis  in  these  instances  is  due  entirely  to  the  peritoneal 
irritation  set  up  by  the  contact  of  free  blood  with  its  -cells.  In  twenty- 
four  or  forty-eight  hours  this  slight  leukocytosis  disappears  and  the 
entire  blood  picture  is  a  normal  one.  Now  if,  as  usually  is  the  case,  re- 
peated small  hemorrhage  occurs,  the  leukocyte  count  will  rise  with  each 
fresh  outpouring  of  blood,  until,  after  several  such  hemorrhages  have 


i34  EXTRA-UTERINE  PREGNANCY 

taken  place,  the  white  count  may  reach  11,000  or  12,000  and  remain  at 
this  figure  for  several  days. 

By  this  time  the  red  cells  will  generally  be  found  slightly  decreased 
in  number  and  the  hemoglobin  is  slightly  lowered. 

When  a  sudden  and  profuse  hemorrhage  develops,  the  red  cells  and 
hemoglobin  are  sharply  diminished,  while  a  few  hours  after  the  hemor- 
rhage the  white  count  becomes  fairly  high — 20,000  to  25,000. 

In  cases  of  severe,  sudden  hemorrhage,  the  writer  regards  a  high 
leukocyte  count  as  fairly  direct  indication  of  the  amount  of  blood  lost, 
the  white  cells  rising  in  direct  ratio  to  the  severity  of  the  hemorrhage. 
The  polynuclear  cells  also  rise  rapidly  in  percentage  under  the  condition 
of  large  intraperitoneal  hemorrhage. 

The  hemoglobin  count  is  not  of  great  value  in  ectopic  pregnancy, 
since  there  is  no  immediate  drop,  and  the  lowest  point  is  not  reached 
until  forty-eight  to  seventy-two  hours  after  the  involved  vessel  has  under- 
gone rupture. 

The  highest  leukocyte  count  noted  by  Taylor  in  his  series  of  cases 
was  46,000,  with  a  polynuclear  cell  percentage  of  95.  In  Farrar's  series 
only  one  case  had  a  leukocyte  count  above  25,000,  while  Foskett  in  117 
cases  found  a  white  count  of  20,000  or  over  in  17,  with  a  corresponding 
increase  in  the  polynuclear  cells. 

There  is  a  considerable  factor  of  error  in  statistics  concerning  blood 
counts  in  ectopic  gestation,  since  the  writers  do  not  specify  the  nature 
of  the  lesion  in  detail,  and  do  not  separate  the  cases  of  slight  rupture  or 
beginning  tubal  abortion,  such  as  are  under  discussion  here,  from  those 
of  violent  and  profuse  hemorrhage. 

To  sum  up  the  condition  of  the  blood  in  this  group,  it  may  be  said 
that  the  existence  of  a  mild  leukocytosis,  not  above  12,000  cells,  which 
develops  within  a  few  hours  of  an  attack  of  pelvic  pain,  subsides  in  48 
hours,  and  rises  again  coincident  with  another  attack  of  pain,  is  sug- 
gestive of  the  presence  of  an  ectopic  pregnancy,  with  small  and  repeated 
hemorrhage  into  the  peritoneal  cavity,  especially  if  the  red  cell  count 
and  the  hemoglobin  proportion  show  no  reduction  from  the  normal. 

Blood  Pressure  usually  is  unchanged,  and  variations  of  pressure 
are  of  no  diagnostic  import,  unless  the  hemorrhage  is  of  the  profuse  type, 
which  will  be  considered  elsewhere.  A  most  important  fact  in  the  semi- 
ology of  ectopic  pregnancy  is  that  the  symptomatology  is  generally 
that  of  a  subacute  disease,  rather  than  one  of  fulminant  type. 

Sudden  onset  of  the  so-called  tragic  type,  without  previous  warning 
of  the  presence  of  pelvic  pathology,  is  the  exception  rather  than  the 
rule.    The  usual  type  is  that  in  which,  after  the  menstrual  disturbances, 


DIAGNOSIS  AND  SYMPTOMATOLOGY  135 

as  described,  have  been  noted  by  the  patient,  there  is  a  short,  but  not 
overwhelming  attack  of  abdominal  pain,  followed  by  uterine  bleeding. 
The  pain  may,  and  frequently  does,  entirely  disappear  for  a  period  of 
days  or  even  weeks,  to  recur  in  repeated  exacerbations  until  the  case 
terminates  in  one  of  these  ways — either  a  sudden  violent  attack  of  pain, 
with  massive  intraperitoneal  hemorrhages,  shock,  syncope  and  collapse, 
with  death  or  recovery  upon  operative  interference,  or  a  continuance  of 
attacks  of  pain,  with  slow  hemorrhage,  gradual  severe  anemia,  infection 
of  the  hematocele  and  death  from  exhaustion  or  sepsis,  unless  recovery 
results  from  successful  surgery. 

A  third  termination  occurs  much  more  commonly  than  is  generally 
supposed.  That  is,  the  ovum  dies,  either  as  a  result  of  rupture  of  the 
tubal  wall  or  by  tubal  abortion,  the  hemorrhage  ceases  spontaneously, 
and  the  clot  remains  uninfected,  to  be  gradually  resorbed,  with  the  com- 
plete recovery  of  the  patient,  who  may  have  been  entirely  ignorant  of 
her  condition,  supposing  her  illness  to  have  been  due  to  an  early  abortion, 
a  view  frequently  shared  by  the  medical  attendant. 

Recovery  is  rarely  complete,  however,  since  adhesions  usually  form 
about  the  affected  tube,  drawing  it  into  contact  with  the  area  occupied 
by  the  hematocele  in  the  cut  de  sac  of  Douglas,  and  leaving  a  condition 
strongly  suggestive  of  an  old  low  grade  unilateral  salpingitis,  for  the 
relief  of  which  the  patient  sooner  or  later  comes  to  operation.  On  ex- 
posing the  internal  genitalia  there  are  found  the  evidences  of  a  damaged 
tube,  with  no  evidence  of  purulent  change,  but  with  fairly  dense  adhesions, 
causing  the  tube  and  ovary  to  lie  fixed,  behind  the  uterus. 

The  writer  has  noted  this  condition  in  several  instances,  and  in  one 
case,  at  least,  there  were  found,  on  careful  examination,  syncytial  shadows 
in  the  tubal  wall,  which  were  evidently  the  remains  of  old  chorion 
formation. 

The  diagnosis  of  ectopic  gestation,  if  properly  made,  at  the  stage  of 
beginning  tubal  abortion  or  minute  rupture,  will  obviously  result  in 
the  institution  of  operative  procedure  before  any  great  damage  is  done 
by  severe  hemorrhage,  and  when  such  operative  interference  is  practiced 
at  this  time,  the  mortality  will  be  surprisingly  low.  The  diagnosis  should 
be  easily  determined,  provided  careful  study  of  each  case  be  carried  out, 
and  if  all  the  facts  be  collected  and  logically  scrutinized.  The  whole  mat- 
ter has  been  excellently  epitomized  by  Philander  Harris,  who,  writing  in 
1907,  says,  "When  any  woman  after  puberty  and  before  menopause,  who 
has  menstruated  regularly  and  painlessly,  goes  four,  five,  six,  eight,  ten, 
fifteen  to  eighteen  days  over  the  time  at  which  menstruation  is  due,  see? 
blood  from  the  vagina  differing  in  quality,  color,  quantity  or  continuance 


136  EXTRA-UTERINE  PREGNANCY 

from  her  usual  menstrual  flow,  and  has  pains,  generally  severe,  in  one 
side  of  the  pelvis  or  the  other,  or  possibly  in  the  hypogastric  region, 
ectopic  pregnancy  may  be  presumed." 

The  Diagnosis  of  Ectopic  Pregnancy  when  frank  rupture  of  the 
tube  or  rapid  tubal  abortion  has  taken  place,  with  massive  hemorrhage 
into  the  peritoneal  cavity. 

In  entering  into  the  consideration  of  this  group  of  cases,  one  is 
struck  with  the  repetition  of  the  word  tragic  in  the  literature.  Indeed, 
so  apt  is  that  designation,  that  certain  writers  divide  cases  into  those  of 
the  pretragic  and  those  of  the  tragic  stage.  Here  it  is  that  the  early 
mortality  was  appalling,  and  herein  lies  one  of  the  signal  triumphs  of 
gynecology,  that  with  the  multiplication  of  competent  operators,  the 
widespread  development  of  the  hospital  idea,  and  the  diagnostic  knowl- 
edge of  the  condition,  so  generally  possessed  by  the  medical  profession, 
and  to  some  degree,  even  by  the  laity,  the  mortality,  even  at  a  time  when 
the  tides  of  life  are  at  their  lowest  ebb,  and  when  each  feeble  cardiac 
contraction  seems  certain  to  be  the  last,  has  been  reduced  from  75  and 
85  per  cent  to  6  or  10  per  cent  at  the  most. 

The  classical  description  of  the  symptomatology  of  sudden  tubal  rup- 
ture, with  violent  hemorrhage,  has  been  quoted  and  taught  so  extensively, 
that  any  serious  medical  student,  if  confronted  with  the  symptom  com- 
plex as  presented  in  textbook  descriptions,  can  hardly  fail  of  a  diagnosis. 

Unfortunately,  the  sudden  rupture  of  a  pregnant  tube  very  frequently 
is  followed  by  a  train  of  events  far  removed  from  that  so  generally 
thought  to  be  connected  with  the  accident. 

It  has  been  the  habit  of  the  writer  to  divide  these  cases  into  two  great 
divisions,  which,  for  lack  of  a  more  accurately  descriptive  terminology, 
have  been  termed  asthenic  and  sthenic.  The  two  are  found  fairly  equally 
divided,  the  former  somewhat  in  the  majority. 

The  asthenic  group  of  cases  includes  those  women  in  whom  rupture 
of  a  pregnant  tube  produces  a  reaction  of  which  depression  is  the  domi- 
nant factor.  These  are  the  women  who,  while  engaged  in  household 
duties  or  while  walking  about,  are  suddenly  and  without  premonitory 
symptoms  seized  with  an  agonizing  and  lancinating  pain  in  the  lower 
abdomen,  which  is  usually  accompanied  by  extreme  nausea  and  vomiting, 
to  be  rapidly  followed  by  syncope,  collapses  and  shock.  The  pulse  is 
of  a  steadily  increasing  rate  and  equally  decreasing  volume,  with  cold, 
clammy,  leaking  skin,  subnormal  temperature,  pallid  features,  the  skin 
frequently  of  a  lemon  tint  by  reason  of  the  extreme  anemia,  rapid  and 
shallow  respirations,  with  frequent  sighing,  contracted  pupils,  a  facies 


DIAGNOSIS  AND  SYMPTOMATOLOGY  137 

of  extreme  anxiety,  intense  restlessness,  thirst,  air  hunger,  and  with 
mentality  unimpaired,  indeed  often  too  sharply  acute. 

Examination  reveals  an  abdomen  possibly  slightly  distended,  rigid 
on  the  affected  side,  and  often  exquisitely  tender  to  palpation.  On 
vaginal  examination,  the  posterior  vaginal  fornix  is  bulged  with  clots, 
and  presents  a  doughy  feel  to  the  ringer.  The  ruptured  tube  is  not  usually 
to  be  palpated,  since  it  is  imbedded  in  recent  clot  and  its  outlines  are 
obscure. 

The  urine  is  scant,  but  otherwise  unchanged.  The  blood  shows  no 
great  disturbance  of  its  red  cells  during  the  first  few  hours,  though  later 
profound  anemia  is  demonstrated  by  the  hemoglobin  estimation.  The 
leukocytes  rise  rapidly  in  number,  with  a  corresponding  preponderance  of 
polynuclear  cells.  For  example,  in  one  fatal  case  occurring  in  the  writer's 
experience,  the  leukocyte  count  registered  24,600  with  92  per  cent  poly- 
nuclear cells,  a  hemoglobin  of  70  per  cent,  and  erythrocytes  to  the  number 
of  2,680,000,  the  count  being  made  six  hours  after  the  sudden  onset  of 
symptoms.  The  blood  pressure  is  usually  low,  90  to  no  systolic,  but 
the  pulse  tension  remains  constant,  and  herein  lies  a  most  important 
diagnostic  feature,  for  which  we  are  indebted  to  Polak,  who  pointed  out 
that  pulse  pressure  remains  fairly  constant  in  cases  of  intraperitoneal 
hemorrhage,  i.e.,  the  ratio  between  systolic  and  diastolic  pressure  does  not 
markedly  change,  both  rising  or  falling  together.  In  cases  of  shock,  on 
the  other  hand,  there  is  usually  a  marked  irregularity  in  the  pulse  pressure, 
the  ratio  between  systolic  and  diastolic  pressure  varying  sharply  from 
time  to  time. 

Needless  to  say,  the  history  of  patients  presenting  such  train  of 
symptoms  will  usually  coincide  with  that  typical  of  ectopic  gestation  as 
previously  outlined,  and  careful  questioning  will  generally  bring  out  the 
fact  that  there  have  been  one  or  more  attacks  of  pelvic  pain,  not  neces- 
sarily of  sufficient  severity  to  cause  the  woman  to  suspect  any  serious 
pelvic  lesion,  but  characteristic  in  behavior. 

There  are  two  local  signs,  which,  when  demonstrable,  are  of  diagnostic 
value. 

Pallor  of  the  cervix  uteri  on  inspection  has  been  described  as  a 
sign  of  value.  In  one  case  in  the  practice  of  the  writer  the  blanched, 
white  appearance  of  the  cervix,  when  distended  by  the  speculum,  was  in 
sharp  contrast  to  the  deep  and  congested  vaginal  mucosa,  and  when  the 
fundus  uteri  was  exposed  upon  opening  the  abdomen,  the  entire  uterine 
body  was  seen  to  be  pallid  and  bloodless. 

Another  sign  only  occasionally  noted,  but  of  value  when  present,  is 
a  bluish  black  discoloration  about  the  umbilical  region.   This  was  demon- 


138  EXTRA-UTERINE  PREGNANCY 

strated  by  Cullen,14  who  reports  the  following  case:  A  woman  thirty- 
eight  years  of  age  suddenly  developed  abdominal  pain  and  distention. 
Dr.  Cullen  saw  her  three  weeks  later.  The  umbilical  region  was  bluish 
black,  although  she  gave  no  evidence  of  injury.  Vaginal  examination 
yielded  nothing,  on  account  of  the  abdominal  distention.  Under  ether, 
however,  a  mass  eight  by  six  centimeters  was  clearly  felt  to  the  right 
of  the  uterus.  Extra-uterine  pregnancy  was  at  once  diagnosed,  although 
the  patient  had  missed  no  period  and  there  was  no  uterine  bleeding.  On 
opening  the  abdomen  he  found  a  right  sided  extra-uterine  pregnancy 
and  about  one  and  one  half  quarts  of  free  blood  in  the  abdomen. 

Hematinemia  and  jaundice  as  diagnostic  signs  have  been  described  by 
Schottmuller,15  who  found  that  "in  cases  of  jaundice  of  obscure  origin 
the  discovery  of  hematin  in  the  blood  serum  served  to  confirm  the 
suspicion  of  a  ruptured  extra-uterine  pregnancy  in  one  of  the  cases  he 
relates.  The  spectroscope  revealing  the  hematin  indicated  the  necessity 
for  an  immediate  operation,  which  was  followed  by  speedy  recovery ;  the 
history  and  palpation  findings  had  suggested  a  benign  ovarian  cyst.  In 
two  other  cases  the  small  proportion  of  hematin,  while  confirming  the 
diagnosis  of  extra-uterine  pregnancy,  yet  showed  that  there  could  not 
have  been  much  extravasation  of  blood,  and  both  the  patients  recovered 
without  complications  or  operation.  He  has  encountered  four 
cases  of  jaundice  with  extra-uterine  pregnancy  in  the  last  year;  the 
tendency  to  jaundice  was  evident  only  in  the  conjunctivae,  but  this  was 
enough  to  suggest  hematinemia,  and  the  spectroscope  confirmed  it. 
Urobilin  was  evident  in  the  urine  in  some,  but  not  all  of  the  cases."  The 
writer  has  had  no  experience  with  this  phenomenon. 

Dullness  in  the  flanks  on  percussion  has  been  described,  but  has  not 
been  noted  by  the  writer,  nor  has  DeLee  seen  this  phenomenon. 

Retention  of  urine  occasionally  occurs,  Farrar  recording  it  in  four  of 
her  1 86  cases. 

The  diagnosis  of  this  asthenic  type  of  case  usually  presents  no 
difficulties,  the  sudden  onset,  the  intensity  of  the  symptoms,  and  the 
profound  depression  of  the  vital  activities  being  so  marked  as  to  at 
once  direct  attention  to  the  fact  that  rupture  of  a  large  intra-abdominal 
vessel  has  occurred.  Differentiation  must  be  made  between  ectopic  preg- 
nancy, a  ruptured  intestinal  ulcer,  and  tubal  or  ovarian  hemorrhage,  the 
result  of  lesions  not  connected  with  an  aberrant  pregnancy.  These 
differential  points  will  be  discussed  at  the  appropriate  place. 

The  sthenic  type  of  reaction  of  the  organism  to.  such  an  event  as  the 
rupture  of  an  extra-uterine  pregnancy  is  not  found  in  descriptions  of 
this  accident,  and  the  writer  has  not  seen  this  very  common  clinical 


DIAGNOSIS  AND  SYMPTOMATOLOGY  139 

picture  discussed  at  any  length  in  the  literature  devoted  to  the  subject. 

In  certain  robust,  florid  women  the  rupture  of  a  tubal  pregnancy  with 
intraperitoneal  hemorrhage  gives  rise  to  a  reaction,  in  which  all  of  the 
physiological  activities  are  stimulated  rather  than  depressed,  as  in  the 
classical  or  asthenic  group. 

Such  a  patient  will  present  the  characteristic  previous  history,  which 
marks  her  as  predisposed  to  ectopic  gestation,  and  has  had  the  usual 
amenorrhea,  followed  by  attacks  of  pelvic  pain  more  or  less  severe  and 
attended  by  uterine  bleeding.  The  frank  rupture  occurs  with  sudden 
violent  pain  in  one  or  the  other  iliac  fossa,  possibly  with  nausea,  vomiting 
or  syncope,  from  which  the  patient  rallies  in  a  short  time,  after  which 
the  abdominal  pain  becomes  generalized  and  acute,  the  temperature  rises 
to  101  to  103  degrees,  the  pulse  remaining  full  and  strong,  of  excellent 
volume  and  rarely  above  no  in  rate.  There  is  a  sharp  leukocytosis, 
averaging  above  12,000,  no  marked  hemoglobin  alteration,  and  no 
especial  diminution  of  the  number  of  erythrocytes.  Blood  pressure  is 
usually  slightly  above  normal,  pulse  tension  remaining  constant. 

On  physical  examination,  the  face  is  anxious,  though  usually  not 
pallid  and  the  mucous  membranes  retain  their  healthy  tint.  The  abdomen 
is  distended,  moderately  tympanitic,  and  extremely  tender  to  pressure. 
Marked  rectus  rigidity  is  the  rule,  usually  most  intense  on  the  affected 
side.  Vaginal  examination  may  or  may  not  disclose  the  presence  of  a 
tubal  mass,  though  usually  there  is  the  vague  sensation  of  a  doughy 
fullness  in  the  cul  de  sac.  A  diagnostic  point  of  value  here,  as  in  the  other 
type  of  case,  is  the  extreme  tenderness  elicited  upon  bimanual  exam- 
ination. There  is  usually  some  slight  bleeding  from  the  softened  cervix, 
though  this  feature  may  be  entirely  absent.  Obviously,  the  resemblance 
of  the  above  symptom  complex  to  that  of  an  acute  inflammatory  process, 
acting  in  the  lower  abdomen,  is  so  clear,  the  physical  findings  so  parallel 
each  other  in  the  two  conditions,  and  in  both  the  clinical  course  of  the 
patient  is  so  similar,  that  diagnosis  presents  the  greatest  difficulties.  It  is 
common  to  find  such  cases  diagnosticated  as  acute  salpingitis  and  treated 
expectantly,  until  the  temperature  falls  to  normal  and  all  evidence  of 
acute  pathological  process  has  subsided,  when,  on  the  performance  of  a 
laparotomy,  and  not  until  then,  is  the  true  existence  of  the  lesion 
recognized. 

Happily  such  diagnostic  error  does  not  result  in  any  harm  being  done 
the  patient.  Inasmuch  as  the  life  of  the  embryo  is  destroyed  at  the  time 
of  rupture  and  the  hemorrhage  ceases  spontaneously,  there  remains  an 
aseptic  hematocele,  which,  on  operation,  is  usually  found  to  be  under- 
going absorption  or  contraction.     Its  removal  is  accomplished  without 


140  EXTRA-UTERINE  PREGNANCY 

undue  difficulty  and  uneventful  recovery  is  the  rule.  The  only  significant 
diagnostic  points  in  this  type  of  case  are  the  characteristic  ectopic  history, 
the  enlargement  of  the  uterus  with  bleeding,  and  the  extreme  tenderness 
of  the  palpated  tube.  Amenorrhea  followed  by  bleeding,  however,  is  a 
common  incident  of  acute  salpingitis,  so  that  for  practical  purposes  there 
remains  but  the  history  and  the  excessive  tenderness  as  definite  points 
on  which  to  base  a  diagnosis. 

A  typical  case  of  this  variety  is  the  following,  which  occurred  in  the 
practice  of  the  writer.  A  strong,  healthy  woman  of  34  years,  who  had 
borne  four  children  normally,  had  had  one  miscarriage  with  some  fever 
following,  two  years  before  coming  under  observation.  She  had  missed 
one  period  and  after  three  weeks  complained  of  some  pain  in  the  right 
side.  There  was  no  uterine  bleeding  nor  was  the  pain  severe  enough  to 
lead  the  patient  to  consult  a  physician.  While  engaged  in  household 
duties,  the  woman  began  to  complain  of  a  sharp  pain  in  the  right  iliac 
fossa,  which  rapidly  grew  intense  and  forced  her  to  lie  down.  She  was 
seen  by  Dr.  Wm.  G.  Shields,  Jr.,  and  by  him  referred  to  the  writer's 
service  at  Frankford  Hospital. 

On  admission  her  condition  was  as  follows :  Temperature  102. 40  R, 
pulse  96,  respiration  20,  leukocytes  13,000,  hemoglobin  85  per  cent,  red 
cells  4,600,000.  Blood  pressure  130-75.  The  face  was  flushed,  the 
chest  was  negative,  the  abdomen  tympanitic  and  very  rigid,  the  right 
rectus  muscle  being  board-like  in  consistency.  The  entire  abdomen  was 
extremely  tender. 

On  vaginal  examination,  the  uterus  was  fairly  large  and  movable, 
though  pressure  and  manipulation  of  the  slightly  softened  cervix  oc- 
casioned great  pain.  There  were  none  of  the  general  or  local  signs  of 
early  pregnancy.  An  exquisitely  tender,  small  mass  was  palpable  in  the 
region  of  the  cut  de  sac.  A  provisional  diagnosis  of  acute  salpingitis 
with  pelvic  peritonitis  was  made,  and  the  patient  placed  upon  expectant 
treatment.  In  considering  the  case  with  the  house  staff,  after  the 
examination  had  been  concluded,  the  intensity  of  the  pelvic  pain  on 
pressure  drew  the  writer's  attention  to  one  case  he  had  previously  seen, 
and,  on  the  strength  of  this  point  and  the  history  above,  the  diagnosis 
was  altered  to  that  of  a  ruptured  tubal  pregnancy  and  immediate  opera- 
tion was  performed.  The  right  tube  was  the  seat  of  an  early  tubal 
pregnancy,  which  had  undergone  rupture,  and  the  abdomen  was  literally 
full  of  liquid  and  clotted  blood.  The  rupture  in  the  isthmus  of  the  tube 
was  one  millimeter  in  diameter,  and  a  portion  of  the  oval  sac  was  pro- 
truding from  the  rent.  There  was  no  evidence  of  any  inflammatory 
process  whatever.     The  tube  was  excised,  the  incision  closed,  and  the 


DIAGNOSIS  AND  SYMPTOMATOLOGY  141 

patient  made  an  eventless  recovery.  Although  a  massive  intraperitoneal 
hemorrhage  had  taken  place  in  this  case,  there  were  absolutely  no  clinical 
data  upon  which  to  base  a  diagnosis  of  such  accident,  and,  as  has  been 
said,  the  history  and  the  inordinate  tenderness  were  the  sole  points 
upon  which  a  diagnosis  of  ectopic  pregnancy  could  be  formulated. 

The  Diagnosis  of  Long  Existing  and  Untreated  Ectopic  Gesta- 
tion    (hematocele,  tubal  mole,  lithopedion  formation,  etc.). 

The  older  literature  is  replete  with  discussions  anent  the  recognition 
and  treatment  of  encapsulated  masses  of  blood  clot,  occupying  the  pelvic 
cavity,  and  usually  of  long  standing,  the  condition  termed  hematocele.  As 
time  went  on,  the  space  devoted  to  consideration  of  the  hematocele  and 
its  treatment  became  steadily  smaller,  until,  in  the  most  recent  works 
along  these  lines,  the  subject  is  dismissed  with  but  a  scant  paragraph 
or  two. 

The  reason  for  the  change  in  thought  is,  of  course,  that  following 
the  generally  disseminated  knowledge  concerning  ectopic  gestation  and 
its  almost  universal  treatment  by  immediate  operation,  the  occurrence 
of  hematocele,  like  that  of  vesicovaginal  fistula,  has  so  diminished  as  to 
be  an  almost  negligible  factor  in  either  diagnosis  or  treatment.  Hemato- 
cele has  previously  been  defined  as  an  encapsulated  mass  of  blood  clot, 
usually  filling  the  pouch  of  Douglas,  and  occasionally  extending  laterally 
to  the  uterus. 

It  results  from  the  rupture  of  a  vessel  in  the  peritoneal  cavity,  with 
consequent  intraperitoneal  hemorrhage,  which  later  undergoes  partial 
absorption,  fibrinization,  and  forms  a  dense,  elastic  mass  closely  applied 
to  the  posterior  surface  of  the  uterus  and  molded  into  the  cul  de  sac. 

Not  uncommonly  the  hematocele  has  been  the  seat  of  an  infection, 
which  on  subsiding  has  left  a  tissue  of  peritubal  and  peri-ovarian  ad- 
hesions in  its  wake.  The  symptomatology  of  this  condition  is  vague  and 
obscure.  There  is  usually  long  continued  dull  pelvic  pain,  periodically 
more  or  less  severe,  according  to  the  general  condition  of  the  patient  and 
the  amount  of  exhausting  physical  effort  performed  by  her.  Dyspareunia 
is  commonly  noted.  On  physical  examination,  there  are  no  blood  or 
urinary  changes,  except  the  hematocele  be  undergoing  an  acute  or  sub- 
acute suppuration,  when  leukocytosis  is  the  rule,  together  with  some  eleva- 
tion of  temperature. 

Rigidity  of  the  rectus  muscles  is  not  present,  nor  is  there  apparent 
any  special  tenderness  when  the  abdomen  is  lightly  palpated.  On  vaginal 
examination,  there  will  be  found  a  firm,  elastic  mass  in  the  pouch  of 
Douglas,  with  the  uterus  riding  upon  it  anteriorly.     The  latter  organ 


142  EXTRA-UTERINE  PREGNANCY 

is  generally  fixed  and  immovable.  Both  adnexa  are  adherent  and  the 
parametrium  fixed  and  dense. 

Diagnosis  between  such  conditions  and  old  chronic  salpingitis  is  not 
to  be  made  from  the  physical  findings,  and  is  only  rendered  possible  by 
the  development  of  a  history  of  a  previous  train  of  symptoms,  pointing 
to  the  rupture  of  a  tubal  pregnancy. 

Puncture  of  the  cul  de  sac  with  an  aspirating  needle  has  been  advo- 
cated, the  withdrawal  of  blood  confirming  the  diagnosis  of  hematocele. 
This  procedure  is  but  of  doubtful  value,  since,  if  the  clot  be  sufficiently 
organized,  no  blood  will  escape  through  the  needle,  and  in  addition  there 
is  a  certain  danger  of  infection  in  this  process,  which  is  entirely  un- 
necessary, since  the  operative  measures  indicated  in  the  treatment  of 
both  hematocele  and  old  salpingitis  are  identical.  A  most  interesting  case 
of  this  type  occurred  in  the  practice  of  the  writer :  A  woman  of  34,  who 
had  borne  no  children  and  had  no  record  of  miscarriage,  had  been  com- 
plaining for  two  years  of  general  pelvic  pain,  worse  on  exertion  and  at 
the  menstrual  period.  The  pain  was  always  dull,  though  at  times  quite 
severe.  There  were  associated  dyspareunia  and  leukorrhea.  On  exami- 
nation, the  temperature  and  pulse  were  normal,  leukocytes  were  8,500, 
hemoglobin  85  per  cent,  and  there  was  nothing  suggestive  in  the  general 
physical  condition  of  the  patient. 

On  vaginal  examination,  the  uterus  was  found  fixed,  a  dense  hard 
mass  filling  the  cul  de  sac  and  extending  along  the  inferior  border  of 
both  broad  ligaments,  with  both  tubes  and  ovaries  fixed,  enlarged  and 
adherent.  Provisional  diagnosis  of  chronic  salpingitis  and  parametritis 
was  made  and  the  patient  admitted  to  Frankford  Hospital  for  operation. 
When  the  usual  detailed  hospital  history  was  studied,  it  was  noted  that 
the  patient  stated  she  had  had  a  period  of  amenorrhea  four  years  pre- 
viously, which  was  followed  by  a  sudden  severe  pelvic  pain,  with  syncope 
and  confinement  to  bed  for  three  weeks,  after  which  she  recovered, 
menstruation  reappeared,  and  she  resumed  her  usual  life.  On  the  basis 
of  this  history  alone  the  diagnosis  was  changed  to  that  of  old  ruptured 
ectopic  pregnancy  with  pelvic  hematocele. 

On  exposing  the  pelvic  region  by  laparotomy,  there  was  found  a 
large,  old,  encapsulated  blood  clot,  which  had  evidently  undergone  in- 
flammatory change,  since  the  tubes  and  ovaries  were  closely  adherent  to, 
it.  The  case  eventuated  in  a  difficult  hysterectomy,  from  which  the 
patient  made  a  good  recovery. 

Microscopical  examination  of  the  tissues  removed,  disclosed  an  old 
tubal  mole  in  the  right  tube,  with  distinct  evidence  of  a  large  rupture  on 
the  superior  surface.    This  case  is  cited  to  again,  emphasize  the  immense 


DIAGNOSIS  AND  SYMPTOMATOLOGY  143 

importance  of  a  careful  history  in  the  diagnosis  of  ectopic  pregnancy  in 
all  its  phases. 

The  Diagnosis  of  Ectopic  Pregnancy  Other  Than  Tubal. — 
Interstitial,  or,  as  the  writer  prefers  to  term  it,  cornual  pregnancy,  was 
formerly  regarded  as  extremely  rare,  Tait  finding  only  six  specimens  in 
English  museums  up  to  1890.  At  the  present  time,  with  the  growth  of 
accurate  diagnostic  methods  and  prompt  surgical  intervention,  this  lesion 
is  known  to  be  comparatively  common. 

The  diagnosis  is  difficult  before  rupture  and  usually  impossible  after 
this  accident,  since  the  phenomena  are  identical  with  those  of  a  ruptured 
tubal  pregnancy.  In  this  connection  the  differential  diagnosis  is  of  no 
import,  since  clinically  the  two  conditions  are  identical  and  the  same 
treatment  is  indicated  for  both. 

Rupture  of  an  interstitial  pregnancy  is  a  grave  lesion,  owing  to  the 
tension  under  which  the  distended  uterine  muscle  labors,  and  to  the  very 
rich  blood  supply  of  this  portion  of  the  uterine  body.  The  diagnosis 
before  rupture  depends  upon  the  usual  ectopic  history,  the  variable 
presence  of  the  associated  signs  of  pregnancy,  and  particularly  the  detec- 
tion, upon  vaginal  examination,  of  an  irregular  enlargement  extending 
around  one  uterine  horn  and  merging  completely  with  the  general  contour 
of  that  organ.  There  is  never  a  pedicle  or  any  area  of  differentiation 
between  the  enlarged  horn  and  the  uterus  proper.  The  enlarged  area 
may  present  a  sense  of  great  tension  and  very  firm  distention,  and  the  tube 
and  ovary  may  be  of  normal  outline. 

In  the  diagnosis  of  cornual  pregnancy,  the  following  mistakes  are 
commonly  made,  according  to  Kustner;16  on  the  one  hand  they  are 
thought  to  be  cases  of  normal  pregnancy,  with  marked  hypertrophy  of 
the  cervix,  the  true  uterine  cavity  being  mistaken  for  the  cervical  canal, 
and  on  the  other  hand  they  have  been  considered  as  incomplete  abortions, 
the  muscular  diaphragm  next  the  uterine  cavity  being  mistaken  for  an 
extremely  well  marked  contraction  ring. 

Pain  is  early  and,  in  contradistinction  to  that  of  tubal  pregnancy, 
usually  develops  before  bleeding  or  death  of  the  ovum  occurs,  this  being 
due  to  the  fact  that  the  uterine  horns  withstand  distention  badly  and  pain 
begins  shortly  after  even  slight  distention  takes  place. 

An  excellent  illustrative  case  is  one  reported  by  the  writer.17  The 
patient  was  a  lady  of  thirty-four  years,  the  wife  of  a  physician.  Her 
previous  history  was  uneventful,  menses  regular  and  normal,  no  illness 
of  note.  She  had  previously  borne  two  healthy  children,  the  first  labor 
a  slow  instrumental  one,  the  second  easy  and  spontaneous.  She  had  had 
two  early  miscarriages  in  the  first  years  of  her  married  life.    In  February, 


144  EXTRA-UTERINE  PREGNANCY 

191 1,  she  noticed  some  delay  and  irregularity  in  the  menses.  This  con- 
dition persisted  until  May,  when  there  developed  absolute  amenorrhea 
with  the  subjective  symptoms  of  pregnancy.  The  patient  then  began  to 
complain  of  a  steady  dull  pain  in  the  right  iliac  fossa,  which  was  at  times 
aggravated  by  severe  lancinating  attacks  of  great  violence.  On  at  least 
two  occasions  there  was  a  slight  bloody  discharge,  simulating  a  scant 
menstruation. 

When  examined  by  the  writer,  the  patient  presented  the  usual  signs 
of  pregnancy,  blueness  of  the  vaginal  mucous  membrane,  engorgement 
of  the  breasts,  nausea,  etc.  Upon  vaginal  examination  the  uterus  was 
found  irregularly  enlarged  to  the  size  of  a  grapefruit.  The  main  en- 
largement was  on  the  right  side  of  the  fundus  uteri,  a  large,  fairly  dense 
mass,  of  smooth  contour  and  apparently  continuous  with  the  body  of  the 
uterus,  which  was  itself  hypertrophied  and  boggy  in  consistency.  A 
tentative  diagnosis  of  some  form  of  ectopic  pregnancy  was  made,  and 
the  patient  referred  to  Dr.  B.  C.  Hirst  for  his  counsel.  Dr.  Hirst  con- 
sidered the  case  one  of  cornual  pregnancy  and  advised  expectant  treat- 
ment, in  the  hope  that  the  gestation  might  be  converted  into  an  intra- 
uterine one  and  go  normally  to  term.  Treatment  by  rest  and  careful 
avoidance  of  exertion  were  accordingly  instituted,  but  after  a  trial  of 
three  weeks,  the  pain  and  discomfort  became  so  marked  that  the  patient 
demanded  relief  and  operation  was  determined  upon. 

On  June  24,  after  a  thorough  preparation  for  abdominal  section,  the 
cervical  canal  was  dilated,  under  ether  anesthesia,  and  the  uterus  digitally 
explored.  The  organ  was  enlarged  and  flaccid,  with  a  large,  dense  mass 
occupying  the  right  cornual  region  and  bulging  into  the  cavum  uteri. 
A  distinct  septum  of  thick,  soft  but  resistant  tissue  separated  the  cornual 
mass  from  the  general  uterine  cavity.  This  septum  presented  a  small 
central  opening,  which  was  readily  dilatable  with  the  finger,  giving  ad- 
mittance to  the  fetal  sac.  There  was  found  a  normal  four  months'  fetus 
with  its  membranes  and  placenta  intact,  the  entire  ovum  lying  within 
the  thinned  out  uterine  horn  and  extending  into  the  uterine  extremity  of 
the  tube.  The  myometrium  was  thinned  out  to  a  barely  palpable  tissue, 
and  gave  a  tactile  impression  of  marked  attenuation.  By  means  of  a 
placental  forceps  the  fetus  and  placenta  were  easily  removed.  The  latter 
organ  presented  a  characteristic  appearance,  being  much  flattened  and 
having  at  one  side  a  long,  finger-like  prolongation,  which  had  extended 
through  the  uterine  cornu  and  had  been  attached  for  a  considerable 
distance  along  the  lateral  aspect  of  the  tube.  There  was  noted  a  general 
development  of  decidual  tissue  throughout  the  entire  uterine  cavity,  which 


DIAGNOSIS  AND  SYMPTOMATOLOGY  145 

was  curetted.  The  patient  made  an  uneventful  recovery  and  was  dis- 
charged from  the  hospital  in  two  weeks. 

After  rupture,  the  various  varieties  of  ectopic  gestation  cannot  be 
separated  from  a  diagnostic  standpoint,  though,  as  has  been  said,  the 
symptoms  are  usually  grave  by  reason  of  the  rich  blood  supply  and  the 
consequent  rapidity  of  the  hemorrhage. 

A  case  of  this  type  was  that  of  a  woman  of  36  years,  who  had  been 
married  ten  years  and  had  never  become  pregnant.  She  had  noted  an 
amenorrhea  for  two  months  preceding  her  illness,  and  had  suffered  from 
a  constant  rather  severe  pain  in  the  left  iliac  fossa,  almost  in  the  midline, 
but,  inasmuch  as  she  was  aware  of  the  existence  of  an  old  salpingitis, 
she  laid  no  special  stress  on  the  presence  of  pelvic  pain.  Suddenly,  while 
on  a  street  car,  she  was  seized  with  a  most  excruciating  attack  of  left- 
sided  pain,  fainted,  and  fell  into  profound  collapse.  She  was  admitted  to 
the  Frankford  Hospital  and  seen  by  the  writer  two  hours  after  the 
initial  attack. 

Examination  revealed  a  woman  apparently  moribund,  pulseless, 
facies  lemon  yellow  in  hue,  there  were  present  extreme  restlessness  and 
anxiety,  shallow  respiration  and  a  cold  clammy  skin.  The  systolic  blood 
pressure  was  80,  diastolic  55.  Hemoglobin  was  70,  red  cells,  3,200,000 
and  leukocytes  10,000.  The  abdomen  was  rigid,  but  not  tender,  the 
patient's  condition  being  almost  beyond  pain  sensation.  Vaginal  exami- 
nation was  not  made,  a  diagnosis  of  ruptured  ectopic  gestation  being 
reached  without  this  procedure. 

Following  the  policy  of  the  writer's  clinic,  immediate  laparotomy  was 
done,  venoclysis  with  a  solution  of  sodium  bicarbonate  being  performed 
synchronously  with  the  administration  of  the  anesthetic,  which  was 
scarcely  necessary. 

On  opening  the  peritoneum,  an  immense  amount  of  blood  was  found 
in  the  cavity  and  the  left  uterine  cornu  was  seen  to  have  literally  ex- 
ploded, the  rupture  being  a  stellate  one,  several  of  the  lines  of  laceration 
extending  well  into  the  fundus  uteri.  The  cornu  was  excised  with  the 
tube,  the  uterus  closed,  and  the  abdominal  incision  united  with  hasty 
suture.  The  patient  reacted  promptly  and  made  an  uneventful  con- 
valescence, leaving  the  hospital  on  the  fourteenth  day.  No  embryo  was 
found  nor  was  any  careful  search  instituted. 

Ovarian  Pregnancy. — This  rare  and  interesting  variety  of  extra- 
uterine gestation  has  been  considered  at  length  in  another  part  of  this 
book  and  presents  no  features  which  permit  of  its  diagnosis  before  rup- 
ture of  the  gestation  sac,  nor  are  there  any  distinctive  signs  after  rupture 
which  serve  to  differentiate  it  from  other  forms  of  ectopic  pregnancy. 


146  EXTRA-UTERINE  PREGNANCY 

Diagnosis  is  only  to  be  reached,  after  removal  of  the  specimen,  by 
the  most  thorough  and  painstaking  microscopic  examination. 

Abdominal  Pregnancy. — It  has  previously  been  stated  that  pri- 
mary abdominal  pregnancy,  while  a  theoretical  possibility,  is  not  clinically 
demonstrable,  and  therefore  all  cases  of  this  type  are  to  be  regarded  as 
secondary  to  tubal  rupture  or  abortion.  The  diagnosis  of  abdominal 
pregnancy  depends  first  upon  the  history  of  an  acute  attack  of  illness, 
which  corresponds  to  the  rupture  of  an  ectopic  pregnancy. 

Should  the  ovum  not  be  destroyed  by  the  rupture,  development  may 
continue  and  the  fetus  grow  and  live  to  maturity.  Such  a  pregnancy  is 
abnormal  in  that  the  fetal  movements  are  far  more  vigorous  and  demon- 
strable than  where  the  uterine  wall  lies  between  the  fetus  and  the  abdom- 
inal parietes.  Vague  abdominal  pain  is  also  a  common  symptom,  this 
being  due  in  part  to  the  aberrant  location  of  the  placenta,  whose  villi  may 
encroach  upon  and  imbed  themselves  in  any  of  the  abdominal  viscera,  and 
in  part  to  the  irritative  effect  of  the  fetus  and  its  envelopes  upon  the 
visceral  and  parietal  peritoneum. 

On  palpation  of  the  abdomen,  the  observer  is  struck  with  the  near- 
ness of  the  fetus  to  the  examining  hand,  as  though  the  child  lay  just 
under  the  skin.  Usually  the  fetus  is  excessively  movable,  it  being  possible 
to  displace  it  from  one  abdominal  quadrant  to  another. 

On  vaginal  examination,  there  is  always  found  the  comparatively 
small  uterus,  which  may  or  may  not  be  displaced  as  the  fetus  lies  on  one 
or  the  other  side  or  above  the  fundus.  The  cervix  is  soft,  but  there  is 
no  evidence  of  Hegar's  sign,  nor  can  ballottement  be  demonstrated. 

The  fetal  extremities  are  usually  to  be  easily  felt  through  the  vaginal 
vault,  a  matter  of  the  utmost  difficulty  in  intra-uterine  pregnancy.  The 
symptoms  of  peritoneal  irritation  are  usually  well  marked,  nausea, 
vomiting,  alternating  constipation  and  diarrhea  with  occasional  in- 
testinal hemorrhage,  and  frequent  and  painful  micturition. 

Should  the  fetus  die,  it  becomes  at  first  macerated,  giving  rise  to  a 
low  grade  infection  with  subfebrile  temperature  and  rather  profound 
toxemia,  these  symptoms  later  subsiding  as  the  fetus  becomes  converted 
into  a  lithopedion  or  an  adipocere. 

Should  the  fetus  live  to  maturity,  there  supervenes,  at  term,  what  is 
known  as  false  labor,  to  be  recognized  by  the  increased  activity  of  the 
fetal  movements,  painful  uterine  contraction,  and  usually  some  vaginal 
bleeding.  These  signs  continue  for  a  short  time,  when,,  by  reason  of 
fetal  death,  the  movements  cease,  as  do  the  uterine  contractions  and  the 
hemorrhages.     Mild  toxemia   follows  and  the  case  is  eventually  con- 


DIAGNOSIS  AND  SYMPTOMATOLOGY  147 

verted  into  one  of  lithopedion  or  other  final  change  in  the  composition  of 
the  fetal  tissues. 

The  Diagnosis  of  Lithopedion  or  Adipocere. — Terminal  changes 
in  the  abdominal  fetus  convert  it  into  what  is  a  pedunculated  benign 
tumor  of  the  abdominal  cavity,  usually  connected  with  contiguous  viscera 
by  fairly  dense  adhesion  formation.  Such  lesions  have  been  borne  with- 
out symptoms  for  many  years  and  give  rise  to  no  clinical  signs,  which 
might  render  a  diagnosis  positive.  When  symptoms  referable  to  these 
growths  do  arise,  and  the  tumor  is  discovered,  it  is  usually  mistaken  for 
a  pedunculated  fibroid,  unless  a  clear  history  of  an  unfruitful  pregnancy 
with  false  labor  be  obtained ;  or  possibly  X-Ray  examination  may  disclose 
the  nature  of  the  growth. 

The  diagnosis  of  abdominal  pregnancy,  then,  is  to  be  made,  during  the 
life  of  the  fetus,  by  the  history  of  an  attack  of  acute  illness,  which  cor- 
responds to  tubal  rupture  or  tubal  abortion,  by  the  fact  that  the  uterus  is 
small  and  not  in  direct  relation  to  the  fetal  body,  by  the  generally  atypical 
subsequent  course  of  the  pregnancy  and  by  the  position  of  the  fetus,  which 
rarely  occupies  the  midline  and  which  may  be  much  more  easily  palpated 
when  lying  free  among  the  intestinal  coils  than  when  intra-uterine.  The 
X-Ray  may  be  of  service,  as  brought  out  by  Zurhille,18  who  says  it  has 
been  claimed  by  other  observers  that  the  differential  diagnosis  of  ad- 
vanced extra-uterine  pregnancy  may  be  confirmed  by  the  position  of  the 
fetus,  which  is  asymmetrical  as  regards  the  mid  plane  of  the  pelvis.  In 
Zurhiile's  case  the  fetal  shadow  was  present  in  this  position,  and  he  sug- 
gests than  a  sound  be  carefully  introduced  into  the  uterus  before  the 
exposure  is  made,  so  that  the  relation  of  the  uterine  cavity  to  the  shadow 
of  the  fetal  skeleton  may  be  established.  If  this  is  carefully  done  and  a 
living  intra-uterine  pregnancy  excluded,  no  harm  can  result  to  the  patient. 

The  Diagnosis  of  Complicated  Ectopic  Gestation. — Extra- 
uterine pregnancy  may  be  coincident  with  an  intra-uterine  gestation. 
Diagnosis  under  these  circumstances  usually  presents  marked  difficulties 
and  is  not  often  made  until  the  marked  sign  of  a  massive  mtra-peritoneal 
hemorrhage  clarifies  the  situation. 

If  the  signs  of  a  normal  intra-uterine  pregnancy,  the  history,  vaginal 
cyanosis,  uterine  enlargement,  etc.,  be  associated  with  pain  in  one  or 
the  other  iliac  fossa,  and  should  any  evidence  of  the  occurrence  of  intra- 
peritoneal hemorrhage  supervene,  the  question  of  a  coincident  tubal 
pregnancy  must  be  considered.  In  such  cases  the  vaginal  bleeding,  so 
characteristic  of  ectopic  pregnancy,  is  usually  absent.  There  may  be 
found,  on  examination,  a  tender  mass  in  one  or  the  other  of  the  vaginal 
fornices,  but  such  findings  are  rarely  significant,  since  pyosalpinx,  small 


148  EXTRA-UTERINE  PREGNANCY 

ovarian  cysts  and  the  like,  give  strikingly  similar  impressions.  Usually, 
the  plan  to  be  followed  in  such  a  case  is  immediate  hospitalization  of  the 
patient  and  a  careful  observance  of  temperature,  blood  pressure,  and  blood 
changes  and  other  evidence  of  continuing  hemorrhage. 

Exploratory  laparotomy  should  be  performed  as  soon  as  there  is 
a  reasonable  belief  that  ectopic  gestation  may  exist.  Absolute  diagnosis 
before  frank  rupture  is  usually  impossible. 

The  Differential  Diagnosis  of  Ectopic  Pregnancy. — Extra-uterine 
gestation,  after  partial  or  complete  rupture  of  the  sac,  closely  simulates 
a  number  of  intra-abdominal  lesions,  so  closely  in  many  instances  as  to 
render  differentiation  a  matter  of  extreme  difficulty. 

In  this  order  of  their  frequency,  the  conditions  most  likely  to  be  con- 
founded with  extra-uterine  pregnancy  are : 

Intra-uterine  pregnancy  with  threatened  abortion, 

Hemorrhage  from  the  tube  or  ovary,  not  in  relation  to  pregnancy, 

Acute  salpingitis, 

Acute  appendicitis, 

Ovarian  cyst  with  twisted  pedicle, 

Rupture  of  a  gastric  or  duodenal  ulcer, 

Ureteral  or  renal  colic. 

By  all  odds  the  most  common  error  in  diagnosis  is  the  confusion  be- 
tween ectopic  pregnancy  and  early  abortion  of  a  normally  implanted 
ovum.  Indeed,  in  studying  case  histories,  it  is  surprising  to  note  how 
large  a  number  of  the  patients  have  been  subjected  to  curettage,  in  the 
belief  that  they  were  suffering  from  an  early  intra-uterine  abortion. 

Furthermore,  it  is  a  fairly  common  occurrence  that  these  women, 
believing  themselves  pregnant,  seek  to  terminate  the  gestation  by  self- 
induced  or  criminal  abortion.  In  Foskett's  series,  12  of  the  117  patients 
thought  themselves  pregnant,  and  seven  attempted  to  induce  abortion  by 
instrumentation  or  drug  taking,  or  both. 

In  Farrar's  series  of  186  cases,  curettage  was  done  before  entrance 
into  the  hospital,  in  the  belief  that  intra-uterine  abortion  existed,  in  16 
instances,  8.6  per  cent.  Owing  to  the  close  parallelism  of  the  symptoms 
and  physical  findings,  the  differentiation  between  these  two  conditions 
usually  presents  marked  difficulty,  and  in  certain  cases  a  definite  diagnosis 
is  almost  impossible,  except  by  direct  inspection  of  the  tubes  by  means  of 
an  exploratory  laparotomy.  Close  study,  however,  will  clear  up  the 
question  in  the  great  bulk  of  the  cases,  the  diagnosis  resting  upon  the 
following  points  of  difference : 

The  pain  of  ectopic  pregnancy  is  usually  severe  at  its  onset,  changing 


DIAGNOSIS  AND  SYMPTOMATOLOGY  149 

in  a  few  hours  from  a  lancinating,  stabbing  sensation  to  a  severe,  dull, 
generalized  abdominal  distress.  In  intra-uterine  abortion  the  pain  is 
cramp-like,  intermittent,  and  steadily  grows  more  severe  as  the  uterine 
contractions  increase  in  frequency  and  force. 

The  pain  of  extra-uterine  pregnancy  is  almost  always,  at  first,  local- 
ized distinctly  in  one  or  the  other  iliac  fossa,  while  in  intra-uterine  abor- 
tion it  is  central,  over  the  region  occupied  by  the  fundus  uteri. 

The  presence  of  free  blood  in  the  cut  de  sac  of  Douglas  causes 
usually  very  intense  pain  on  defecation,  together  with  considerable  rectal 
tenderness.     This  symptom  is  wanting  in  intra-uterine  abortion. 

The  bleeding  varies  to  some  degree  in  the  two  conditions.  In  intra- 
uterine abortion  the  hemorrhage  is  generally  profuse  and  the  blood  is 
bright  red  in  color. 

In  ectopic  pregnancy,  the  hemorrhage  is  apt  to  be  small,  and  the 
blood  is  brownish  and  has  been  described  as  slimy  in  consistency.  Vaginal 
examination  is  rarely  productive  of  definite  findings,  but  in  general  it 
may  be  said  that  the  cervix  is  softer  and  shows  more  dilatation  when 
the  abortion  is  intra-uterine  than  when  small  rupture  or  beginning  tubal 
abortion  of  a  tubal  pregnancy  has  taken  place. 

The  discovery  of  a  mass  occupying  the  site  of  a  fallopian  tube  and 
exquisitely  tender  to  palpation  inclines  the  diagnosis  toward  tubal  preg- 
nancy, the  conviction  being  strengthened  by  the  elicitation  of  a  boggy, 
soft,  indefinite  mass  in  the  cut  de  sac.  The  general  physical  examination 
reveals  certain  differences.  Temperature  is,  as  a  rule,  higher  in  ectopic 
pregnancy  than  in  abortion,  unless  the  latter  be  of  the  induced  type,  or 
if  the  uterus  has  become  infected.  The  temperature  in  tubal  pregnancy, 
after  small  hemorrhage,  usually  reaches  100  to  101  degrees,  while  in 
aseptic  intra-uterine  abortion,  it  rarely  rises  above  990,  unless  and  until 
infection  supervenes. 

Leukocytosis  of  low  degree  is  common  in  extra-uterine  pregnancy, 
uncommon  in  uterine  abortion.  Hemoglobin  change  occurs  only  late,  if 
at  all,  in  both  conditions,  and  is  therefore  valueless  as  an  aid  to  diagnosis. 
The  extrusion  from  the  uterus  of  any  portion  of  an  embryo,  or  frag- 
ments of  chorion,  shown  by  a  miscroscopic  examination,  render  the 
diagnosis  of  uterine  abortion  conclusive. 

A  blanched  appearance  of  the  cervix  has  been  described  as  a  diagnostic 
sign  of  rupture  in  ectopic  pregnancy,  but  such  phenomenon  is  to  be 
expected  only  after  profuse  hemorrhage,  in  which  case  more  definite 
characteristic  symptoms  should  be  present. 

A  strongly  positive  Wassermann  reaction  should  incline  one  toward  a 
diagnosis  of  uterine  abortion,  although  the  fact  that  a  woman  is  infected 


i5o  EXTRA-UTERINE  PREGNANCY 

with  syphilis  does  not  militate  in  any  way  against  her  developing  extra- 
uterine pregnancy. 

The  history  presents  few  points  of  difference,  though  the  essential 
facts  which  point  to  the  patient  being  apt  for  pathological  conception  must 
be  given  due  weight;  one  child  sterility,  previous  pelvic  infection,  con- 
servative gynecological  operation,  or  ectopic  pregnancy  should  predispose 
the  observer  to  a  diagnosis  of  ectopic  gestation. 

In  the  absence  of  any  conclusive  evidence,  resort  is  sometimes  had 
to  posterior  colpotomy,  depending  on  the  presence  or  absence  of  free 
blood  in  the  abdominal  cavity  to  determine  the  diagnosis. 

The  writer  is  not  at  all  in  accord  with  this  practice,  feeling  that  should 
a  ruptured  tubal  pregnancy  be  discovered,  operation  for  the  relief  of  the 
condition  must  be  performed  via  the  vagina,  the  worst  possible  route  for 
the  excision  of  the  pregnant  tube,  and  the  one  most  prone  to  be  followed 
by  infection  of  the  pelvic  cavity. 

A  sign  of  some  value  is  the  persistence  of  uterine  bleeding  of  mild 
degree  after  curettage  has  been  practiced.  This  sign  is  ordinarily  nega- 
tived by  the  fact  that  but  few  of  these  cases  are  subjected  to  curettage, 
and  that  even  among  these  free  rupture  with  massive  intraperitoneal 
hemorrhage  takes  place  before  enough  time  has  elapsed  to  regard  the  con- 
tinuing uterine  hemorrhage  as  significant. 

Summing  up,  thus,  the  essential  features  of  a  differential  diagnosis 
between  ectopic  pregnancy  with  beginning  rupture  and  uterine  abortion, 
it  may  be  said  that  the  conditions  present  striking  similarity,  but  that 
in  uterine  abortion  the  bleeding  is  more  free,  the  blood  bright  red,  the 
cervix  is  more  widely  dilated,  the  pain  is  markedly  less,  is  spasmodic  in 
type,  located  in  the  region  of  the  uterus  and  steadily  grows  worse  as 
the  abortion  proceeds,  while  in  ectopic  pregnancy  the  pain,  usually  local- 
ized over  one  or  the  other  tube,  begins  suddenly  with  great  violence,  not 
unfrequently  attended  by  nausea  and  syncope,  and  steadily  grows  less  in 
severity,  to  be  replaced  within  a  few  hours  by  a  dull,  generalized,  abdom- 
inal ache.  Abdominal  rigidity  is  more  marked  in  ectopic  pregnancy,  the 
temperature  is  higher,  and  moderate  leukocytosis  is  present.  In  uterine 
abortion  the  uterus  is  apt  to  be  large,  and  there  is  no  palpable  mass  in 
either  tubal  region,  except  in  those  extremely  puzzling  cases  where  a 
subacute  or  chronic  salpingitis  is  coincident  with  a  uterine  abortion. 

An  interesting  and  illustrative  case,  presenting  the  difficulties  some- 
times encountered  in  reaching  a  correct  conclusion  in  this  connection,  is 
one  reported  by  Oastler.19  "Mrs.  S.  W.,  age  twenty-eight  years,  with 
a  negative  previous  history.  Her  first  labor  was  normal  and  regular 
menstruation  was  resumed  six  weeks  after  weaning.     The  patient  went 


DIAGNOSIS  AND  SYMPTOMATOLOGY  151 

two  weeks  beyond  term  and,  thinking  she  was  pregnant,  tried  to  induce 
an  abortion.  Bleeding  commenced  in  twenty-four  hours  and  a  dull  pain 
in  the  lower  abdomen  was  noted  about  forty-eight  hours  later.  The 
bleeding  continued  for  five  days,  when  the  patient  came  under  Dr.  Oast- 
ler's  care.  At  that  time  she  complained  of  discomfort  in  the  lower  abdo- 
men and  stated  that,  since  the  effort  to  induce  abortion,  she  had  become 
constipated,  a  condition  from  which  she  had  never  before  suffered.  There 
was  no  nausea  and  no  increased  frequency  of  micturition.  Examination 
of  the  abdomen  was  negative,  and  no  tenderness  could  be  elicited.  Vaginal 
examination  showed  the  uterus  somewhat  enlarged  and  soft,  with  the 
cervix  normal.  Ovaries  and  tubes  were  apparently  normal,  and  a 
diagnosis  of  incomplete  abortion  was  made.  The  patient  was  curetted, 
but  nothing  was  found,  and  she  continued  to  flow,  but  had  no  pain.  Not 
having  bled  for  five  days,  the  patient  was  again  examined,  and  the  results 
differed  from  the  preceding  one  in  only  a  single  respect ;  a  small  mass  was 
felt  in  the  right  lateral  fornix,  which  was  hard,  movable,  and  appeared 
like  an  ordinary  cystic  ovary.  With  the  history  of  a  missed  period, 
negative  curettage,  sudden  onset  of  constipation,  slight  general  pain, 
continued  bleeding  notwithstanding  curettage,  and  a  small  mass  not  found 
on  first  examination,  a  diagnosis  of  incomplete  ectopic  gestation  was 
made.  The  operation  revealed  this  condition  in  the  right  tube,  with  a 
small  amount  of  blood  around  the  fimbriated  extremity.  There  were  no 
adhesions  present,  and  the  corpus  luteum  was  not  found  in  the  left  ovary. 
The  right  ovary  was  very  small  and  apparently  atrophied.  The  interest- 
ing feature  in  this  case  was  the  misleading  history  and  physical  signs." 

Differentiation  of  Ectopic  Gestation  from  Acute  Salpingitis. — 
A  ruptured  tubal  pregnancy  of  the  sthenic  type  sometimes  so  closely 
simulates  acute  inflammatory  processes  in  the  tube  that  a  correct  diagnosis 
is  a  matter  of  the  utmost  difficulty.  The  problem  is  to  be  attacked  first 
by  the  securing  of  an  accurate  and  detailed  history,  and,  as  has  been 
repeatedly  stated,  the  matter  of  the  history  in  cases  of  suspected  extra- 
uterine pregnancy  cannot  be  too  greatly  stressed.  There  is  usually  a 
known  or  demonstrable  cause  for  the  development  of  salpingitis,  especially 
if  the  patient  comes  under  observation  during  the  acute  stage  of  the 
disease. 

A  recent  abortion,  followed  by  a  period  of  febrile  reaction,  an  attack 
of  appendicitis,  recent  gonorrhea,  easily  to  be  demonstrated  by  vaginal 
and  cervical  smears,  will  all  serve  to  point  to  the  existence  of  tubal  in- 
flammation. The  manner  of  onset  of  the  attack  is  a  valuable  point  in 
differentiation.  In  salpingitis,  the  symptoms  usually  come  on  gradually, 
a  steadily  increasing  pelvic  pain  being  usually  associated  with  leukorrhea, 


152  EXTRA-UTERINE  PREGNANCY 

the  maximum  intensity  of  the  pain  generally  not  reached  for  several  days 
after  its  being  first  noted.  Whereas  in  extra-uterine  pregnancy  the  pain 
begins  suddenly  and  undergoes  marked  amelioration  for  a  day  or  more, 
to  be  followed  by  renewed  attacks. 

Physical  examination  generally  results  in  a  rather  confusing  com- 
bination of  signs  and  symptoms,  often  so  misleading  as  to  make  a 
definite  diagnosis  almost  impossible.  Both  conditions  are  associated  with 
febrile  reaction,  though  the  fever  resulting  from  pyogenic  inflammation 
is  usually  higher  than  that  produced  by  the  mere  irritative  action  of 
blood  upon  the  peritoneal  nerve  endings.  Leukocytosis  is  present  in 
both  conditions,  but  is  generally  higher  where  salpingitis  exists  than 
when  the  lesion  is  a  ruptured  pregnant  tube.  The  exception  to  this  is  in 
those  cases  of  extra-uterine  pregnancy  wherein  very  large  intraperitoneal 
hemorrhage  has  taken  place,  in  which  instances  the  white  count  may 
reach  from  2.5,000  to  30,000.  In  this  type  of  case,  however,  the  as- 
sociated clinical  evidences  of  massive  hemorrhage  are  usually  so  pro- 
nounced that  determination  of  the  lesion  should  offer  no  untoward  diffi- 
culties. On  vaginal  examination,  there  is  rarely  any  special  enlargement 
of  the  uterus  with  salpingitis,  while  only  in  unusual  instances  is  there  any 
considerable  softness  of  the  cervix.  Uterine  bleeding  is  uncommon,  but 
may  occur.  The  mass  palpated  in  tubal  inflammatory  disease  is  gen- 
erally much  more  definitely  outlined  and  circumscribed  than  in  tubal  preg- 
nancy, and  the  tenderness  is  not  nearly  so  marked  on  pressure  by  the  ex- 
amining finger  as  in  the  latter  condition.  In  salpingitis,  there  is  com- 
monly present  a  parametritis,  demonstrable  by  a  dense  firm  consistency 
of  the  vaginal  vault  with  fixation  of  the  uterus,  such  findings  being  rare 
in  ectopic  pregnancy.  The  concomitant  signs  of  pregnancy  are  wanting 
in  cases  of  inflammatory  disease,  while  they  are  generally  present  in 
some  degree  in  the  presence  of  tubal  pregnancy. 

In  summing  up  the  features  of  variation  of  salpingitis  from  ectopic 
pregnancy,  the  history  is  to  be  regarded  as  of  the  first  importance,  fol- 
lowed by  the  nature  of  the  onset  of  the  attack,  the  fact  that  pulse,  tempera- 
ture and  leukocytosis  are  usually  higher  in  salpingitis,  the  swollen  tube 
more  easily  outlined,  and  the  tenderness  and  pain  on  examination 
markedly  less. 

The  Diagnostic  Separation  of  Ruptured  Extra-Uterine  Preg- 
nancy from  Ovarian  Cysts,  either  with  or  without  torsion  of  the 
pedicle,  is  not  usually  a  matter  of  any  great  difficulty,  but  an  occasional 
case  will  appear  in  which  the  sign  and  symptoms  are  confusing. 

Ordinarily  there  are  not  present  the  characteristic  extra-uterine  his- 
tory, the  amenorrhea,  or  irregular  bleeding.     When  torsion  of  the  cyst 


DIAGNOSIS  AND  SYMPTOMATOLOGY  153 

pedicle  takes  place,  there  may  be  violent  pelvic  pain,  with  syncope  and 
collapse.  Slight  elevation  of  temperature  and  a  moderate  leukocytosis 
may  shortly  follow  the  accident.  On  vaginal  examination,  the  ovarian 
cyst  is  generally  much  larger  than  an  ectopic  pregnancy,  the  uterus  is  not 
enlarged,  nor  is  the  cervix  softened.  Small  retention  cysts  of  the  ovary, 
with  their  attendant  delayed  menstruation  and  the  dull  pelvic  pain  which 
sometimes  goes  with  them,  closely  simulate  extra-uterine  pregnancy,  and, 
indeed,  occasionally  such  cysts  rupture  during  the  course  of  a  vaginal 
examination,  this  accident  making  the  suspicion  of  ectopic  pregnancy  more 
pronounced.  Many  cases  of  this  nature  have  been  promptly  operated 
upon,  in  the  belief  that  a  ruptured  tubal  gestation  was  being  dealt  with, 
only  to  discover  a  small  and  apparently  insignificant  follicular  ovarian 
cyst.  The  history  is  the  only  means  of  differentiation  in  these  instances, 
which  are  among  the  most  difficult  of  correct  interpretation. 

The  differentiation  of  extra-uterine  pregnancy  from  retroversion  of 
the  normally  pregnant  uterus  is  sometimes  a  matter  of  the  greatest  un- 
certainty. Both  conditions  are  attended  by  a  train  of  signs  and  symptoms 
strikingly  similar.  In  both  there  is  bleeding  from  the  vagina,  pelvic  pain, 
perhaps  retention  of  urine;  the  concomitant  signs  of  pregnancy  are  pres- 
ent in  both,  as  is  amenorrhea,  a  softening  of  the  cervix,  and  a  boggy, 
tender  mass  present  in  the  cul  de  sac. 

In  a  retroverted  gravid  uterus,  however,  the  cervix  is  tilted  upward 
and  forward,  pointing  even  sometimes  toward  the  symphysis,  whereas, 
if  the  uterus  be  pushed  forward  by  a  hematosalpinx  or  by  a  collection  of 
blood  in  the  cul  de  sac,  the  cervix  points  backward  and  toward  the 
perineum. 

The  pain  of  a  retroverted,  congested  pregnant  tube  is  apt  to  be  dull 
in  character,  constant,  and  located  over  the  body  of  the  uterus  radiating 
to  the  back.  The  pain  of  ectopic  gestation  has  been  described  as  short 
and  spasmodic  in  character,  followed  by  an  increasing  general  abdominal 
ache  as  the  free  intraperitoneal  blood  sets  up  peritoneal  irritation.  If  the 
uterus  be  sharply  retroflexed,  the  angle  made  by  the  junction  of  cervix 
with  fundus  may  be  clearly  felt,  but  the  abdominal  hand  feels  no  fundus, 
this  portion  of  the  organ  having  disappeared  in  the  hollow  of  the  sacrum. 
The  diagnosis  of  a  combination  of  retroversion  of  the  uterus  plus  ectopic 
pregnancy,  is  extraordinarily  difficult  and  is  to  be  reached  only  after  a 
most  painstaking  survey  of  the  history. 

When,  following  rupture  of  a  pregnant  tube  with  secondary  abdominal 
development  of  the  fetus,  the  uterus  is  crowded  down  below  the  gesta- 
tion sac,  the  diagnosis  offers  great  difficulty.  De  Lee  20  reports  such  a 
case,  which  was  at  first  diagnosed  as  retroversion  of  the  pregnant  uterus 


FIG.   57.— Uterus   Crowded   Down   Below  Gestation    Sac.    From   De   Lee. 


Fig.  58. — Uterus  Pushed  Down  by  Gestation  Sac.    From  De  Lee. 

154 


DIAGNOSIS  AND  SYMPTOMATOLOGY 


155 


with  retention  of  the  urine,  but  when  the  abdominal  tumor  did  not  sub- 
side on  catheterization  and  the  fetus  was  felt  above  the  left  Poupart's 
ligament,  the  correct  condition  was  discovered,  with  operation  and  re- 
covery.    (Figs.  57  and  58.) 


Fig.  59.— Section  Through  Attachment  of  Villi  to  Tube  Wall.    From  Mall. 

Differentiation  of  ectopic  pregnancy  from  ruptured  gastric  ulcer, 
renal  colic,  cholecystitis,  etc.,  should  be  made  after  a  consideration  of  the 
history  of  the  case,  the  absence  of  uterine  bleeding,  and  the  location  and 
character  of  the  pain,  and  will  not  be  discussed  in  detail  here. 

In  closing  the  question  of  diagnosis  in  extra-uterine  pregnancy,  atten- 
tion is  again  called  to  the  importance  of  most  careful  study  of  the  case 


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From     Mall. 


Fig.    6i. — Section    Through    Vacuolated 
Syncytium.    From  Mall. 


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Fig.  62.— Syncytium   Covering  a  Typical  Villus.    From  Mall. 

156 


DIAGNOSIS  AND  SYMPTOMATOLOGY 


157 


history,  as  the  paramount  factor  in  a  correct  interpretation  of  the  symp- 
toms and  signs  of  this  lesion. 

The  Histological  Diagnosis  of 
Extra-Uterine  Pregnancy. — It  fre- 
quently becomes  necessary  to  ascertain 
whether  hemorrhage  from  a  fallopian 
tube  or  an  ovary  is  a  result  of  the  rup- 
ture of  a  gestation  sac,  or  is  due  to 
other  causes. 

Microscopic  examination  should  al- 
ways determine  the  diagnosis,  but  un-    Fig.  63.— Villus   Undergoing  Fibrous 
fortunately  for  the  purposes  of  detailed  Degeneration.    From  Mall. 

study,  most  specimens  of  tubal  or  ovarian  pregnancy  are  so  damaged 
by  the  rupture  of  their  walls  and  the  subsequent  operative  manipula- 


"*4. 

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Fig.  64. — Section  Through  Ovum  Adjoining  Tube  Wall.    From  Mall. 


tion  that  the  tissues  are  distorted  in  their  relations  and  so  greatly  al- 
tered by  traumatism  as  to  make  orderly  study  difficult. 

A  positive  histologic  diagnosis  of  extra-uterine  pregnancy  is  only  to 


,.-..♦  • 


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Fig.  65. — Tip  of  a  Fibrous  Villus.    From  Mall. 


158 


EXTRA-UTERINE  PREGNANCY 


be  made  by  finding  chorionic  villi  or  syncytial  cells  in  the  suspected  tissue. 

So-called  decidual  cells, 
when  found,  do  not  in  them- 
selves constitute  the  evidence 
for  an  affirmative  diagnosis,  as 
they  may  be  present  in  the  tube 
walls  during  intra-uterine  preg- 
nancy, and,  indeed,  when  no 
pregnancy  whatever  exists. 

The  microscopic  picture  of 
a  pregnant  tube  is  well  shown 
in  Figs.  59  to'  69. 

The  chorionic  villi  frequent- 
ly penetrate  the  muscular  coat 
and  may  be  seen  terminating 
just  under  the  serosa. 

Syncytial  cells  are  abundant 
and  there  is  always  noted  an 
attempt  at  reaction  to  the  invading  blastodermic  cells  on  the  part  of 
the  tubal  tissues,  as  evidenced  by  round  cell  infiltrations  and  the  pres- 
ence of  fibrinous  exudate. 


Fig. 


66. — Section  Through  a 
lus.     From  Mall. 


Necrotic  Vil- 


u     "  *   •&-"'**  *    "'  . 

;V    .,,..'.•  4..  :'•/./ 

••,-i/V.v:.ft;,i       V*     A 

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Fig.  67. — Section  of  Vacuolated  Syncytium  Filled  with  Leukocytes.    From  Mall. 

When  the  ovum  has  been  dead  for  some  time,  areas  of  organized 
hemorrhage  are  the  principal  constituents  of  the  tube.    There  are  always 


DIAGNOSIS  AND  SYMPTOMATOLOGY 


159 


to  be  recognized,  however,  the  characteristic  chorionic  villi,  though  per- 
haps in  an  advanced  stage  of  degeneration. 

The  finding  of  an  embryo  is  not 
a  necessary  criterion  of  the  exist- 
ence of  ectopic  pregnancy,  since  the 
fruit  of  the  gestation  is  not  un- 
commonly lost  among  coils  of  in- 
testine, following  the  rupture  of 
the  tube  or  a  tubal  abortion;  or 
the  embryo,  if  very  young,  may 
have  undergone  absorption. 

Evidence  of  villus  formation  is, 
however,  an  absolute  necessity,  if 
the  diagnosis  is  to  be  substantiated. 

The  criteria  necessary  for  the  establishment  of  a  diagnosis  of  ovarian 
pregnancy  have  already  been  enunciated. 


-Extreme  Degeneration  of  the 
Syncytium.     From  Mall. 


.y./p" 

•  •# 

**      . 

# 

:r 

# 

•"* 

> 

1 

iH  >a    " 

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IK*                                    v 

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Fig.  69. — Group  of  Villus  Cells  Growing  into  Mesenchyme.    From  Mall. 

Histologically,  ovarian  pregnancy  will  always  present  syncytium,  even 
though  distinct  villi  be  absent,  although  in  most  of  the  recorded  cases, 
placentation  was  easily  demonstrable. 


i6d  EXTRA-UTERINE  PREGNANCY 

LITERATURE 

i.     Hunner,  G.  L.     Ectopic  Gestation  from  the  Standpoint  of  the 
General  Practitioner.     Am.  Jr.  Obst.      19 10.     62:409. 

2.  Boldt,  H.  J.    The  Diagnosis  of  Extra-Uterine  Pregnancy.    Arch. 

Diag.    Jan.,  1908.    p.  32. 

3.  Farrar,  L.  K.  P.     Am.  Jr.  Obst.     1919.     79:733. 

4.  Foskett,  E.     A  Study  of  117  Cases  of  Ectopic  Gestation.     Am. 

Jr.  Obst.     1913.     67:27. 

5.  Bandler,  S.  W.     Medical  Gynecology.    Philadelphia,  1908.  p.  645. 

6.  Mackenzie,  S.  N.    The  Clinical  Aspects  of  Extra-Uterine  Gesta- 

tion.   Jr.  Obst.  Gyn.  Brit.  Emp.  191 1.    20:277. 

7.  Taylor,  H.  C.     Med.  Surg.  Rep.  Roosev.  Hosp.     1915.    p.  147. 

8.  Rongy,  A.  J.     The  Treatment  of  Ectopic  Gestation,  Based  on  a 

Study  of  100  Cases.    Am.  Jr.  Obst.     1918.    77:86. 

9.  Taylor,  J.  W.     Extra-Uterine  Pregnancy,     p.  102. 

10.  Oastler,  F.   R.     Ectopic  Pregnancy.     Surg.  Gyn.   Obst.      191 7. 

24 :224. 

11.  Polar,  J.  O.     Observations  in  227  Cases  of  Ectopic  Pregnancy. 

Am.  Jr.  Obst.     19 15.    71:946. 

12.  Frank,  R.  T.     An  Analysis  of  Eighty  Consecutive  Cases  of  Ectopic 

Gestation.    Am.  Jr.  Obst.     1909.    59:211. 

13.  Wynne,  H.  M.  N.     Bull.  J.  Hopk.  Hosp.     1919.     30:15. 

14.  Cullen,  T.  S.     Tr.  Am.  Gyn.  Soc.     1918. 

15.  Schottmuller.     Munch,  med.  Woch.     Feb.  3,  1914. 

16.  Kustner.     Ektopik  Schwangerschaft.     p.   118. 

17.  Schumann,  E.  A.     Am.  Jr.  Obst.     1912.    65. 

18.  Zurhille.     Zentbl.  f.  Gyn.     Sept.  27,  1912. 

19.  Oastler,  F.  R.     Am.  Jr.  Obst.     1914.    69:127. 

20.  De  Lee,  J.  B.     Obstetrics.     Philadelphia,  191 5.    p.  402. 


CHAPTER  VII 

TREATMENT 

Treatment  Before  Rupture  Has  Occurred— The  Treatment  of  the  Affected  Tube — 
The  Treatment  of  the  Remaining  Tube — The  Management  of  Abdominal  Lesions, 
Not  Connected  with  the  Ectopic  Pregnancy — The  Closure  of  the  Incision— The 
Treatment  of  Advanced  Extra-Uterine  Pregnancy — The  Treatment  of  Ad- 
vanced Ectopic  Pregnancy  When  the  Fetus  Is  Known  to  Be  Dead— The 
Treatment  of  Infected  and  Suppurative  Ectopic  Pregnancy — The  Treatment  of 
Hematocele — Mortality  and   Prognosis. 

The  greater  portion  of  this  book  consists  of  the  accumulated  data 
compiled  by  many  investigators  and  students  in  the  field  of  extra-uterine 
pregnancy.  This  is  necessary,  since  no  one  operator  can  hope  to  se<i 
even  isolated  cases  of  the  many  varieties  of  this  protean  lesion.  In  dis- 
cussing the  treatment,  however,  the  author  has  thought  it  wise  to  ignore 
the  views  of  other  and  wiser  men,  except  in  so  far  as  their  work  has 
influenced  his  attitude,  and  to  present  in  concise  form  the  treatment  of 
extra-uterine  pregnancy  as  it  appeals  to  him  after  a  considerable  hospital 
experience  with  this  lesion  and  its  results. 

A  consideration  of  treatment  of  extra-uterine  pregnancy  naturally 
divides  itself  into  the  management  of  certain  phases  of  the  condition. 

First :  The  treatment  of  cases,  which,  happily,  are  discovered  be- 
fore rupture  or  hemorrhage  into  the  sac. 
Second:  Treatment  when  rupture  has  occurred,  but  the  location 
of  the  patient  or  difficulty  of  transportation  renders  immediate 
hospitalization  and  operation  impracticable. 
Third :  The  operative  treatment  of  ruptured  ectopic  pregnancy. 
Fourth:  The  treatment  of  advanced  extra-uterine  pregnancy. 
Fifth:  The  treatment  of  sequelae  and  complications  of  ectopic 
gestation. 
Treatment  Before  Rupture  Has  Occurred. — The  epigram  that 
there  is  no  expectant  treatment  for  extra-uterine  pregnancy  is  peculiarly 
applicable  to  the  management  of  those  cases  which  are  suspected  to  be  un- 
ruptured tubal  pregnancy.    The  word  suspect  is  used  advisedly,  since  it  is 
the  firm  conviction  of  the  writer  that  no  positive  diagnosis  of  unruptured 
ectopic  gestation  can  be  made,  the  term  rupture  being  used  in  its  broadest 
sense  to  include  any  separation  of  the  ovum  and  its  envelopes  with 

161 


162  EXTRA-UTERINE  PREGNANCY 

hemorrhage,  either  into  the  tube  wall  or  elsewhere.  The  treatment  of 
the  suspect  case  consists  in  immediate  hospitalization  and  inspection  of 
the  tubes  via  the  abdominal  route  as  soon  as  practicable.  Should  the 
patient  live  in  a  remote  locality,  where  the  transfer  to  a  hospital  involves 
time  and  difficulties  in  transportation,  the  need  for  this  measure  is  only 
the  greater,  since  all  such  difficulties  are  immeasurably  increased  after 
rupture  or  tubal  abortion  has  actually  taken  place. 

Far  better  that  many  women  should  be  subjected  to  annoyance  and 
disturbance  of  their  activities  than  that  one  patient,  in  whom  a  tentative 
diagnosis  of  extra-uterine  pregnancy  has  been  made,  should  perish  as  a 
result  of  intra-peritoneal  hemorrhage  developing  while  she  is  so  situated 
that  immediate  operative  relief  is  impossible. 

The  treatment  of  these  cases  prior  to  their  entering  a  hospital,  or 
while  awaiting  operation  in  such  institution,  should  be  directed 
solely  with  a  view  to  prevention  of  rupture  or  tubal  abortion.  To  this 
end,  vaginal  examinations  and  abdominal  palpation  should  be  minimized, 
and  conducted  only  by  those  having  long  experience  with  this  procedure. 
The  patient  should  be  placed  at  absolute  rest  in  bed,  not  being  allowed 
to  rise  for  any  purpose.  No  active  purgation  should  be  permitted,  low 
enemas  being  sufficient  to  empty  the  colon.  Diet  is  to  be  carefully  regu- 
lated, in  order  to  prevent  possible  attacks  of  diarrhea,  with  its  attendant 
pelvic  congestion  and  tenesmus,  as  well  as  to  anticipate  the  possible  ac- 
cumulation of  gas  in  the  upper  bowel,  with  its  resulting  pressure. 

No  general  or  local  treatment  is  indicated,  but  prompt  exploratory 
operation  should  be  performed  as  soon  as  reasonably  possible.  The 
operative  technic  will  be  later  discussed. 

Second:  Treatment  When  Rupture  of  the  Sac  or  Tubal  Abor- 
tion Has  Occurred  with  Intra-Abdominal  Hemorrhage,  and  when 
the  situation  of  the  patient  makes  immediate  operation  impracticable. 

It  has  been  said  that  extra-uterine  pregnancy  is  commonly  a  subacute 
disease,  with  repeated  hemorrhages  taking  place  at  intervals  of  several 
days,  before  a  final  large  rupture  takes  place,  or  the  patient  is  exsangui- 
nated by  the  constant  repetition  of  small  outpourings  of  blood.  In  such 
cases  the  immediate  treatment  consists  of  absolute  rest,  with  no  change 
from  the  recumbent  position  on  the  part  of  the  patient,  for  any  purpose 
whatever.  An  ice  cap  is  to  be  placed  over  the  lower  abdomen,  being 
only  removed  at  such  intervals  as  are  necessary  to  prevent  cutaneous 
damage  from  the  continued  cold.  The  diet  should  consist  largely  of 
liquids,  which  may  be  given  freely.  Any  food  which  might  give  rise  to 
nausea  and  vomiting,  with  their  attendant  increase  of  intra-abdominal 
pressure,   is  to  be  avoided.     Purgatives   are  taboo,   the  bowels  being 


TREATMENT  163 

evacuated  by  means  of  low  enemata.  No  stimulating  drugs  are  indicated, 
as  it  is  essential  that  blood  pressure  be  not  unduly  raised.  The  sub- 
cutaneous or  intravenous  injection  of  fluids  is  to  be  condemned  in  the 
treatment  of  a  case  under  the  conditions  now  being  considered. 

The  only  drug  of  value  is  morphin,  which  should  be  administered  in 
such  quantities  as  to  induce  rest  and  relaxation  on  the  part  of  the  patient. 
Hypodermic  exhibition  of  morphia  is  preferable  to  administration  in  the 
mouth,  by  reason  of  the  lessened  tendency  to  produce  nausea  and 
vomiting. 

In  the  event  of  the  hemorrhage  increasing  and  the  patient  developing 
the  evidence  of  acute  anemia,  the  extremities  should  be  firmly  bandaged, 
in  order  to  keep  as  much  blood  as  possible  within  the  great  vessels  of  the 
trunk,  and  the  foot  of  the  bed  should  be  elevated,  to  maintain  a  full 
vascularization  of  the  cerebral  centers.  Abundant  external  heat  is  to  be 
applied. 

The  treatment  thus  outlined  should  be  practiced  only  during  the 
period  of  preparation  for  removal  to  a  hospital,  or  while  an  appropriate 
operating  room  is  being  improvised  at  the  home  of  the  patient,  and  the 
necessary  surgeons  and  instruments  obtained. 

Third:  The  Treatment  of  Ruptured  Ectopic  Pregnancy,  when 
Surgical  Facilities  Are  Available. 

It  is  the  definite  opinion  of  the  writer  that  all  cases  of  extra-uterine 
pregnancy  should  be  subjected  to  operation  as  soon  as  practicable,  regard- 
less of  the  condition  of  the  patient.  This  does  not  imply  the  "penknife" 
type  of  surgical  interference,  for  it  seems  needless  to  state  that  to  invade 
the  peritoneal  cavity  without  reasonable  hope  of  asepsis,  and  without 
proper  aid  from  anesthesia,  assistant,  etc.,  is  certain  to  result  in  disaster. 
It  does  imply,  however,  that  the  bleeding  vessel  is  to  be  ligated  at  once, 
the  conditions  being  suitable  for  laparotomy.  As  shown  in  the  section 
devoted  to  the  medical  history  of  ectopic  gestation,  there  was  a  period 
when  the  experiments  of  Hunter  Robb  and  his  followers  had  considerable 
weight  among  the  profession,  and  Robb's  dictum,  "We  feel  justified  more 
and  more  in  believing  that  the  intra-abdominal  hemorrhage,  such  as  is 
met  with  in  women  suffering  from  collapse  after  the  rupture  of  an  ectopic 
gestation,  is  not  sufficient  in  itself  to  cause  a  fatal  termination  in  these 
cases ;  death  is  caused  mainly  by  shock  which  may  be  increased  by  various 
procedures;  the  hemorrhage  per  se  is  rarely,  if  ever,  the  sole  cause  of 
death,"  led  to  delay  in  operating  upon  the  victims  of  rupture  of  the  ectopic 
gestation  sac  in  a  number  of  clinics,  for  a  period  of  several  years.  Let 
us  glance  at  Parry's  statistics  of  500  cases  with  386  deaths,  of  which 
*74>  or  52.88  per  cent,  perished  from  hemorrhage  following  rupture.    Of 


•i64  EXTRA-UTERINE  PREGNANCY 

these  the  period  during  which  life  was  prolonged  is  mentioned  in  113. 
Of  the  whole  113,  81  had  died  at  the  end  of  twenty-four  hours  after  rup- 
ture was  supposed  to  have  occurred,  while  at  the  end  of  forty-eight  hours 
only  15  or  a  little  more  than  13  per  cent  of  the  whole  number  were  alive. 
Truly  a  curious  combination,  these  accurate  statistics,  and  the  assertion 
of  Robb  that  hemorrhage  is  not  per  se  a  cause  of  death  in  ruptured  extra- 
uterine pregnancy! 

The  expectant  plan  of  treatment  was  soon  abandoned,  however,  but 
the  effect  produced  by  it  has  not  yet  entirely  disappeared,  many  .gynecolo- 
gists of  wide  experience  preferring  not  to  operate  in  the  so-called  "tragic 
stage,"  but  to  await  a  reaction  from  the  initial  shock  and  a  recovery  in 
blood  pressure  and  a  lowering  of  pulse  rate,  before  resorting  to  lapar- 
otomy.   With  such  viewpoint  the  author  is  in  no  way  in  accord. 

It  is  not  within  the  ken  of  human  minds  to  foretell  the  result  of  an 
internal  hemorrhage,  and  to  sit  quietly  by,  counting  the  pulse  and  esti- 
mating the  blood  pressure  changes,  hour  by  weary  hour,  while  the  life 
blood  drips  slowly  but  surely  from  the  severed  ends  of  the  torn  vessels, 
hidden  from  sight  in  the  abdominal  cavity,  to  put  off  operative  inter- 
ference until  the  patient,  exsanguinated,  is  at  last  moribund,  to  wait  in 
vain  for  the  reaction  which  does  not  take  place,  is  a  procedure  repugnant 
alike  to  surgical  experience  and  surgical  courage. 

The  writer  holds  firmly  with  that  master  of  the  subject,  Mr.  Lawson 
Tait,  when  he  says,  "For  surgical  hemorrhage,  cut  down  and  tie  the 
bleeding  point;  if  a  big  branch  of  the  femoral  artery  were  bleeding,  my 
colleagues,  who  deal  in  such  cases,  would  cut  down  and  tie  it.  Why 
should  Poupart's  ligament  be  a  line  of  demarcation,  within  which  this 
surgical  writ  will  not  run?  Why  should  my  friend,  Mr.  Bryant,  be  al- 
lowed to  do  to  the  external  iliac  artery  what  I  am  prohibited  from  doing 
to  the  internal  division?"    Why,  indeed! 

There  is  a  deplorable  laxity  with  regard  to  the  terms  used  in 
describing  the  effects  of  the  rupture  of  a  gravid  tube,  and,  as  pointed  out 
by  John  B.  Deaver,  one  of  the  worst  of  these  practices  has  been  the  use 
of  the  word  shock,  to  define  the  symptom  complex  following  such  rupture. 
The  picture,  after  the  first  few  moments,  is  not  at  all  one  of  shock,  but 
corresponds  in  every  detail  to  that  of  severe  and  continuing  intra- 
peritoneal hemorrhage. 

Furthermore,  it  is  the  opinion  of  all  operators  of  large  experience 
that  the  condition  of  the  patient,  pulse  rate,  temperature,  respiration, 
hemoglobin  count,  etc.,  bears  a  direct  relation  to  the  amount  of  blood 
lost.  The  greater  the  hemorrhage,  the  worse  the  patient,  and  vice  versa. 
It  follows,  then,  that  the  use  of  such  "vicious,  catch  phrases"  as  "adding 


TREATMENT  165 

shock  to  shock"  is  not  only  misleading,  but  affords  in  no  sense  true  state- 
ments, since  the  real  fact  is  that,  by  immediate  operation,  one  adds  shock 
(or  rather  the  possibility  of  shock)  to  preexisting  hemorrhage,  a  result 
always  to  be  anticipated  when  dealing  with  any  surgical  hemorrhage 
wherever  situated. 

The  plan  of  awaiting  reaction  from  the  primary  depression  of  hemor- 
rhage in  patients  in  extremis  when  admitted  to  hospital,  has  something 
in  its  favor.  It  is  indubitably  true  that  many,  indeed,  a  majority  of  such 
patients  do  react,  and  may  be  operated  upon  with  comparative  safety 
twenty-four  or  forty-eight  hours  after  reaction.  It  is  equally  true,  how- 
ever, that  no  man  can  foretell  whether  reaction  will  take  place,  or  whether 
the  patient  will  slip  momentarily  further  and  further  beyond  surgical  aid, 
until  the  opportunity  for  interference  has  passed  and  death  ends  the 
scene,  without  any  attempt  having  been  made  to  save  the  life  of  the 
woman. 

It  is  argued  that  one  should  closely  watch  the  two  indices  of  the 
patient's  condition— pulse  rate  and  blood  pressure — and  if  she  is  seen 
to  be  losing  ground,  operate  immediately;  if  she  be  gaining  and  reaction 
is  beginning,  await  a  more  opportune  time. 

Theoretically  this  argument  is  good,  but  practically  speaking,  if  these 
moribund  women  are  watched  until  they  grow  worse,  they  will  have 
perished  before  the  bleeding  vessel  can  be  exposed  and  ligatured.  The 
fact  is  that,  given  a  woman  exsanguinated  from  internal  hemorrhage, 
with  imperceptible  pulse,  rapid  shallow  respiration,  cold  leaking  skin  and 
very  low  blood  pressure,  her  chances  for  recovery  are  far  greater  by 
offering  her  a  combination  of  simultaneous  abdominal  section  and  bold 
stimulation  than  by  any  other  plan  of  treatment  yet  devised. 

The  attitude  of  the  writer  in  this  matter,  then,  is  that  he  would  operate 
upon  every  woman  suffering  from  a  ruptured  ectopic  gestation  as  soon 
as  the  conditions  for  rapid  and  aseptic  laparotomy  are  available,  without 
regard  to  the  condition  of  the  patient.  If  any  evidences  of  life  are  mani- 
fest, the  patient  is  given  the  opportunity  for  recovery  that  is  offered  by 
the  control  of  the  hemorrhage  and  free  stimulation. 

While  it  is  true  that  the  resources  of  surgery  are  rarely  successful 
when  practiced  on  the  dying,  yet  of  all  surgical  conditions,  ruptured 
ectopic  pregnancy  is  the  one  wherein  even  patients  operated  upon  almost 
in  articulo  mortis  recover  with  the  most  surprising  rapidity. 

The  treatment  followed  in  the  author's  service  is  as  follows :  Imme- 
diately upon  a  diagnosis  of  ruptured  ectopic  pregnancy  being  made,  the 
patient  is  given  a  subcutaneous  injection  of  morphiae  sulph.,  grs.  %.  The 
head  of  the  bed  is  lowered  and  bodily  warmth  maintained  by  the  use  of 


166  EXTRA-UTERINE  PREGNANCY 

external  heat.     So  soon  as  the  operating  room  can  be  made  ready  and  the 
staff  assembled,  laparotomy  is  performed. 

Before  beginning  an  operation  of  this  character,  the  steps  to  be  fol- 
lowed should  be  clearly  outlined  in  the  mind  of  the  surgeon,  and  his 
management  of  the  varying  conditions  which  may  be  found  should  be 
definitely  determined,  in  order  that  no  valuable  time  may  be  lost  in  ar- 
riving at  a  decision,  after  the  abdomen  is  opened,  which  should  have 
been  reached  before  the  patient  entered  the  operating  room. 

There  are  always  present  in  these  cases  a  definite  series  of  conditions 
whose  management  must  be  decided : 

The  management  of  free  blood  and  clots  in  the  abdominal  cavity. 

The  treatment  of  the  affected  tube. 

The  treatment  of  the  remaining  tube. 

The  management  of  abdominal  lesions  not  connected  with  the 

ectopic  pregnancy. 
The  closure  of  the  incision. 

Free  blood  and  clots  within  the  abdominal  cavity  are  to  be  removed 
only  in  so  far  as  their  presence  obscures  the  field  of  operation. 

When  the  diseased  tube  has  been  brought  into  view  and  secured  for 
excision,  no  further  effort  is  made  to  remove  blood  and  clots.  Further- 
more, it  is  important  that  the  tube  be  exposed  as  soon  as  possible,  else 
much  valuable  time  may  be  wasted  in  sponging  away  blood  which  has 
already  been  lost  to  the  patient,  while  the  severed  vessel  is  still  bleeding 
unchecked. 

It  is  the  custom  of  the  writer  to  scoop  out  with  the  hands  the  masses 
of  clot  that  usually  present  as  soon  as  the  peritoneum  is  incised,  and  to 
make  no  further  attempt  at  toilet  of  the  peritoneal  cavity  until  the  opera- 
tion is  completed,  when,  depending  upon  the  condition  of  the  patient, 
either  the  residue  of  blood  is  left  behind,  or  a  more  or  less  thorough 
sponging  of  the  abdominal  cavity  is  practiced. 

The  Treatment  of  the  Affected  Tube. — In  the  treatment  of 
the  ruptured  tube,  one  of  three  plans  may  be  followed.  The  tube  may  be 
amputated  just  proximal  to  the  gestation  sac,  leaving  the  stump  as  a 
possible  factor  in  future  uterine  pregnancy.  It  may  be  split  at  the  point 
of  rupture,  and  the  remains  of  the  sac  removed,  after  which  the  incision 
in  the  tube  wall  may  be  sutured  or  left  open  at  the  option  of  the  operator. 
The  tube  may  be  excised  down  to  the  uterine  cornu. 

Inasmuch  as  a  damaged  tube  offers  great  opportunity  for  a  repetition 
of  the  accident  of  ectopic  gestation,  as  shown  by  the  cases  of  Coe,  Taylor, 
Gottschalk,  Stahl  and  others,  and  since  a  tube  so'  traumatized  presents 
but  a  faint  possibility  of  furnishing  an  unobstructed  passageway  for  the 


TREATMENT  167 

ovum  in  the  future,  the  first  two  plans  of  treatment  are  not  advised  nor 
practiced  by  the  writer,  who  holds  with  Cragin  x  that  the  frequency  of 
this  repeated  accident  has  been  great  enough  to  convince  one  of  the 
danger  of  leaving  behind  a  tube  which  has  once  been  the  site  of  an 
ectopic  gestation.  As  regards  the  question  of  whether  a  tube,  once  the 
seat  of  a  tubal  rupture  or  abortion,  will  ever  allow  a  normal  intra-uterine 
pregnancy,  the  writer  can  only  say  that  the  proof  of  this  result  would 
require  the  previous  removal  or  closure  of  the  opposite  tube,  and  he  has 
been  unable  to  find  in  the  literature  any  record  of  a  case  of  normal  preg- 
nancy in  which  the  only  patent  fallopian  tube  possessed  by  the  woman 
had  previously  been  the  site  of  an  ectopic  gestation.  He  would,  there- 
fore, state  the  proposition  that  a  tube  once  the  site  of  an  ectopic  gestation 
should  be  removed,  as  likely  to  be  a  source  of  danger  if  left  behind,  and 
not  likely  to  be  of  value  in  future  child  bearing. 

The  affected  tube,  then,  is  to  be  excised  down  to  the  uterine  cornua. 

The  Treatment  of  the  Remaining  Tube. — Authorities  differ 
greatly  in  their  views  upon  this  phase  of  the  question,  some  advocating 
the  routine  removal  of  both  tubes,  by  reason  of  the  likelihood  of  a  later 
ectopic  pregnancy  developing  in  the  tube  left  behind,  while  others  would 
never  remove  the  unaffected  side.  The  rational  view  seems  to  rest  some- 
where between  these  two  extremes. 

The  value  of  the  unaffected  tube  lies  in  its  offering  possibilities  for 
subsequent  child  bearing  on  the  part  of  the  patient;  the  danger  of  leaving 
it  behind  rests  upon  the  probability  of  its  becoming  the  seat  of  a  future 
tubal  pregnancy,  since  the  causes  underlying  this  condition  are  frequently 
identical  in  both  tubes. 

This  question  has  been  fully  discussed  in  the  section  of  the  book 
devoted  to  Recurrent  Extra-uterine  Pregnancy,  but  a  brief  review  of 
the  facts  is  here  set  down,  since  the  accumulated  experience  of  gynecolo- 
gists forms  the  basis  of  a  rational  treatment. 

In  a  grouped  study  of  the  histories  of  280  patients,  the  victims  of 
ectopic  pregnancy  and  in  whom  there  existed  the  possibility  of  future 
pregnancy  of  any  variety,  35,  or  12.5  per  cent,  suffered  from  repeated 
ectopic  gestations,  while  134  intra-uterine  pregnancies  occurred,  or  47.8 
per  cent,  a  ratio  of  extra-  to  intra-uterine  pregnancy  of  about  1  14. 

It  appears  then  that  about  one  woman  in  eight,  who  has  had  one 
extra-uterine  pregnancy  may  expect  another,  whereas  one  half  the  total 
number  have  the  prospect  of  future  normal  childbirth. 

These  figures  are  so  overwhelmingly  in  favor  of  the  retention  of  the 
unaffected  tube,  that  there  seems  no  valid  argument  left  for  its  removal, 


1 68  EXTRA-UTERINE  PREGNANCY 

provided,  of  course,  that  the  organ  shows  no  evidence  of  gross  disease 
upon  inspection. 

It  is  the  practice  of  the  author  always  to  leave  one  tube,  unless  its 
retention  would  seem  to  invite  further  pelvic  pathology,  to  the  detriment 
of  the  future  health  of  the  patient. 

The  Management  of  Abdominal  Lesions,  Not  Connected  with 
the  Ectopic  Pregnancy. — In  approaching  this  phase  of  the  subject, 
it  should  be  remembered  that  the  rupture  or  abortion  of  a  tubal  gestation 
sac  is  a  lesion  distinctly  traumatic  in  its  nature,  that  the  patient  is  suf- 
fering from  an  acute  injury,  and  that  the  surgical  axiom  that  a  minimum 
of  operative  trauma  insures  a  maximum  of  success  in  treatment  applies 
to  the  management  of  ruptured  ectopic  gestation  as  well  as  to  that  of 
any  other  accident  involving  hemorrhage. 

Therefore  a  general  rule  may  be  advanced  that  no  more  surgery  should 
be  practiced  upon  a  victim  of  such  rupture  than  is  absolutely  necessary  to 
insure  primary  postoperative  recovery. 

Practically  applied,  the  rule  means  that,  when  dealing  with  a  patient 
in  serious  condition  from  hemorrhage  plus  shock,  the  hemorrhage  is  to 
be  controlled  and  the  tube  removed  in  the  shortest  time  possible,  and  the 
operation  terminated  without  regard  to  any  other  pathological  condition 
observed  in  the  abdomen,  save  one  only  and  that  one  of  very  rare  oc- 
currence, namely,  the  presence  of  a  pregnancy  in  the  opposite  tube  which 
may  be  expected  to  rupture  at  any  time.  In  this  event,  it  obviously  be- 
comes necessary  to  excise  both  tubes. 

The  practice  of  systematic  abdominal  exploration,  the  removal  of  the 
appendix,  uterine  suspension  and  the  like  during  the  course  of  an  opera- 
tion for  ruptured  ectopic  pregnancy,  when  there  has  been  a  considerable 
blood  loss  and  the  natural  resistance  of  the  patient  greatly  impaired 
thereby,  is  to  be  unqualifiedly  condemned.  Where  there  has  been  but 
little  bleeding,  as  in  certain  cases  of  tubal  abortion,  and  when  the  patient 
iz  not  in  serious  condition,  the  procedure  may  be  modified,  and  attention 
to  the  coexistent  lesions  is  not  only  justifiable  but  proper.  In  a  general 
sense,  however,  the  author  is  inclined  to  minimize  intra-abdominal 
manipulation,  in  cases  of  ectopic  gestation,  to  the  lowest  possible  degree, 
and  it  is  his  firm  belief  that  every  unnecessary  minute  added  to  the  opera- 
tion time  imperils  the  recovery  of  the  patient  in  direct  ratio.  The  shorter 
and  less  traumatic  the  operation,  the  less  eventful  the  convalescence. 

The  Closure  of  the  Incision. — The  abdominal  incision  in  the  type 
of  case  under  discussion  should  uniformly  be  closed  without  drainage,  it 
being  presumed  that  no  active  infective  process  is  present  within  the 
abdomen.     Drainage  has  no  place  here,  and  if  practiced,  only  tends  to 


TREATMENT  169 

an  infection  of  a  sterile  substance,  which,  however,  is  an  excellent  culture 
medium,  the  clot  and  free  blood  remaining  within  the  peritoneal  cavity. 

Technic. — The  technic  of  laparotomy  for  ruptured  ectopic  pregnancy 
requires  but  brief  description.  Ether  is  the  anesthetic  of  choice,  by 
reason  of  its  stimulant  properties,  and  the  anesthesia  is  begun  with  the 
patient  in  a  moderate  Trendelenburg  position.  This  practice  keeps  the 
head  lowered,  a  desideratum  in  the  case  of  severe  blood  loss,  and  seems 
to  greatly  stabilize  the  respiratory  excursion,  obviating  the  straining  and 
excessive  contraction  of  the  abdominal  muscles  sometimes  noted  when  a 
patient  already  partially  anesthetized  is  placed  in  the  Trendelenburg  posi- 
tion. 

Immediately  after  the  stage  of  excitement  has  passed,  the  arm  of  the 
patient  opposite  the  side  on  which  the  operator  is  to  stand  is  exposed, 
the  cubital  space  prepared,  and  the  median  cephalic  or  basilic  vein  opened 
and  the  intravenous  injection  of  either  normal  saline  solution  or,  better 
still,  a  six  per  cent  solution  of  gelatin  in  water,  is  begun.  The  amount 
introduced  should  be  not  less  than  one  quart  and  not  more  than  three 
pints,  in  case  of  severe  hemorrhage.  The  intravenous  replacement  of 
fluid  may  continue  until  the  required  amount  has  been  introduced,  the 
apparatus  being  moved  with  the  patient  from  the  operating  room  to  her 
bed,  if  necessary. 

At  the  same  time,  if  the  pulse  be  rapid  and  small,  a  hypodermic  in- 
jection of  strych.  sulph.  gr.  1/20  and  atrop.  sulph.  gr.  1/50  is  exhibited. 

While  this  is  going  on,  the  abdomen  is  being  prepared  according  to 
the  routine  of  the  individual  surgeon,  either  by  iodin,  alcohol  and  ether, 
or  a  combination  of  phenol,  acetone  and  alcohol,  a  modification  of  Mc- 
Donald's solution,  which  is  used  exclusively  in  the  author's  service.* 

This  mixture  is  used  to  saturate  wash  cloths,  with  which  the  entire 
operative  field  is  vigorously  scrubbed  for  three  minutes,  the  solution  be- 
ing poured  on  from  a  wash  bottle. 

The  abdomen  is  then  appropriately  draped  and  a  median  incision  is 
made,  generous  in  size,  so  that  no  time  may  be  lost  in  gaining  access  to 
the  pelvic  viscera.  The  diagnosis  is  usually  confirmed  by  the  purplish 
hue  of  the  peritoneum,  caused  by  the  presence  of  blood  in  the  abdominal 
cavity.  When  the  peritoneum  is  incised,  blood  is  not  infrequently  ejected 
with  considerable  force,  owing  to  the  increase  in  intra-abdominal  pres- 
sure brought  about  by  the  presence  of  a  considerable  volume  of  blood. 

*The  formula  used  in  Frankford  Hospital  consists  of 

Phenoco 2  parts 

Acetone 40  parts 

Alcohol    (95   per    cent) to  make  100  parts 


170 


EXTRA-UTERINE  PREGNANCY 


The  presenting  clots  are  scooped  out  with  the  hands,  the  intestines 
isolated  by  means  of  gauze  or  crepe  de  chine  pads  if  necessary,  which  is 
rarely  the  case,  and  the  uterus  grasped  and  brought  into  view.  The  af- 
fected tube  is  grasped  with  forceps  and,  if  a  bleeding  point  is  detected, 
the  hemorrhage  is  controlled  by  a  clamp  on  the  uterine  end  of  the  tube, 
while  another  grasps  the  mesosalpinx. 

The  manner  of  excision  of  the  tube  varies  with  the  condition  of  the 
patient.    If  the  case  be  a  desperate  one,  the  mesosalpinx  is  simply  ligated 


Fig.  70. — Blood  Supply  of  Fallopian  Tube.     From  Norris. 

en  masse  as  a  pedicle  and  the  tube  cut  off.  Usually,  however,  a  greater 
refinement  of  technic  is  permissible,  and  the  blood  supply  of  the  tube  is 
controlled  by  three  ligatures,  preferably  of  No.  1  chromicized  catgut, 
which  are  placed  along  the  upper  border  of  the  broad  ligament,  one  to 
secure  the  outer  branch  of  the  artery  to  the  tube,  just  internal  to  the 
fimbriated  extremity,  one  about  the  middle  of  the  tube,  and  one  well  into 
the  uterine  cornu.  The  tube  is  then  cut  free  from  the  mesosalpinx  and 
its  uterine  end  excised  by  a  wedge  shaped  incision  in  the  uterine  cornu. 
The  open  upper  border  of  the  broad  ligament  is  now  approximated  with 
a  continuous  suture  of  No.  O  chromic  gut,  and  the  operation  is  completed. 
The  blood  supply  of  the  tube  is  shown  by  Fig.  70,  taken  from  Norris,  and 


TREATMENT  171 

the  operative  technic  is  well  illustrated  by  Fig.  71.  The  abdominal  in- 
cision is  closed  by  layer  suture. 

The  postoperative  treatment  of  cases  of  ruptured  ectopic  pregnancy, 
in  which  there  has  been  severe  hemorrhage,  is  conducted  with  a  view  to 
the  correction  of  three  factors  of  danger  to  the  patient;  that  is,  shock, 
acute  anemia,  and  cardiac  dilatation  and  failure,  resulting  from  a  com- 
bination of  the  first  two  factors. 

Shock  is  controlled  by  the  generous  use  of  external  heat,  electric  heat- 
ing pads  being  excellently  adapted  for  the  purpose,  the  retention  of  all 


Fig.  71. — The  Details  of  Salpingectomy  for  the  Removal  of  a  Tubal  Pregnancy. 
Note  the  location  of  the  ligatures  which  control  the  tubal  blood  supply. 

blood  possible  in  the  great  vessels  of  the  head  and  trunk  by  means  of  the 
low  head  position  of  the  bed  and  firm  bandaging  of  the  extremities. 

The  acute  anemia  is  best  overcome  by  direct  blood  transfusion,  when- 
ever this  is  possible,  at  least  500  c.cm.  of  blood  and  more,  if  circum- 
stances permit,  being  transfused.  The  blood  should  be  typed  before  trans- 
fusion is  attempted,  and  the  method  of  choice  is  that  of  the  simple  large 
glass  syringe,  although  the  Kempton-Brown  tubes  may  be  utilized. 

In  the  opinion  of  the  writer,  blood  transfusion  is  by  all  odds  the  most 
important  measure  in  the  treatment  of  a  desperate  case,  its  importance 
bearing  a  direct  ratio  to  the  time  elapsing  between  the  onset  of  the 
hemorrhage  and  the  replacement  of  the  blood.    For  this  reason,  the  ideal 


172  EXTRA-UTERINE  PREGNANCY 

time  for  transfusion  is  during  the  course  of  the  operative  procedure  and, 
when  the  requisite  clinic  and  assistants  are  available,  this  is  the  method  of 
choice.  Transfusion  may  be  practiced  with  benefit  at  any  time  during 
the  convalescence,  but  after  the  first  forty-eight  hours  it  is  not  usually 
required.  Failing  the  requisites  for  blood  transfusion,  saline  or  gelatin 
solution  is  to  be  introduced  by  vein  as  described.  The  surgeon  should 
bear  in  mind  that  too  much  fluid  per  vein  is  almost  as  productive  of 
harm  as  too  little,  since  inundation  of  the  vascular  system  readily  leads 
to  acute  cardiac  dilatation  and  edema  of  the  lungs,  with  probably  fatal 
results.  As  a  general  rule  of  practice,  not  less  than  one  quart  nor  more 
than  three  pints  of  saline  solution  should  be  added  to  the  circulation  at 
one  time. 

Inasmuch  as  the  fluid  is  absorbed  by  the  tissues  in  a  short  time,  it  is 
proper  to  supplement  this  by  the  use  of  saline  solution  by  the  bowel,  the 
institution  to  be  begun  about  four  hours  after  the  completion  of  the 
operation  and  continued  by  the  drop  method  so  long  as  absorption  takes 
place. 

So  soon  as  the  patient  has  reacted  from  the  operation  and  anesthetic, 
anemia  is  treated  by  the  systematic  administration  of  iron  and  arsenic  in 
the  combination  favored  by  the  individual  operator.  A  capsule  of  Blaud's 
mass  gr.  v  with  arsenious  acid  gr.  1/24,  exhibited  three  times  daily,  is 
the  routine  practiced  by  the  writer. 

Cardiac  failure  is  anticipated  and  controlled  in  these  cases  by  the  free 
use  of  cardiovascular  stimulants,  strychnia,  digitalis,  and  atropin  by 
hypodermic  injection  being  needful  to  some  degree  in  most  cases.  Abun- 
dant feeding,  and  the  stimulating  effect  of  fresh  air  and  sunshine  are  im- 
portant factors  in  the  treatment,  most  of  the  writer's  cases  being  moved 
to  the  hospital  sun  porch  on  the  day  following  operation.  Pain  and  rest- 
lessness are  controlled  by  the  free  use  of  morphin.  Laxatives  play  no. 
part  in  the  postoperative  routine,  the  bowels  being  evacuated  by  means 
of  daily  enemata. 

Such,  in  general,  is  the  outline  of  the  treatment  of  these  desperate 
cases.  The  steps  of  the  procedure  vary,  naturally,  with  the  gravity  of  the 
case.  When  hemorrhage  is  slight  and  no  constitutional  signs  of  blood 
loss  are  apparent,  transfusion  and  venoclysis  are  usually  unnecessary,  nor 
is  postoperative  stimulation  required  in  so  drastic  a  form. 

When  the  pregnancy  is  interstitial,  the  hemorrhage  has  usually  been 
profuse,  and  the  trauma  inflicted  upon  the  uterine  horn  is  excessive.  In 
some  instances,  it  is  possible  to  excise  and  close  the  uterine  cornu,  but 
where  this  offers  difficulty  and  appears  to  be  a  time  consuming  procedure, 


TREATMENT  173 

a  quick  supravaginal  hysterectomy  is  the  operation  of  choice.  In  this 
event,  the  unaffected  tube  and  ovary  are  to  be  left  in  situ  in  most  cases. 

Ovarian  pregnancy  is  treated  by  ovariotomy,  the  tube  being  also  re- 
moved in  most  cases.  The  preoperative  and  postoperative  treatment  is 
essentially  that  of  tubal  rupture. 

The  question  naturally  arises,  whether  the  plan  of  immediate  radical 
treatment  is  absolutely  requisite  in  all  cases  of  extra-uterine  pregnancy, 
or  whether  perhaps  there  are  not  some  situations  in  which  a  policy  of 
watchful  waiting  is  not  more  conducive  to  the  well  being  of  the  patient. 

It  has  been  stated  previously  that  there  are  undoubtedly  a  number  of 
cases  of  ruptured  tubal  pregnancy,  in  which  the  true  state  of  affairs  is 
never  recognized  and  from  which  the  women  recover  without  any  sur- 
gical aid. 

There  is  another  and  considerable  group  of  cases,  in  which  rupture 
between  the  folds  of  the  broad  ligament  or  complete  tubal  abortion  has 
taken  place,  the  hemorrhage  ceasing  and  the  ultimate  result  being  either 
a  broad  ligament  hematoma  or  a  pelvic  hematocele,  either  condition  not 
only  presenting  no  indication  for  immediate  operation,  but,  indeed,  pro- 
ductive of  a  somewhat  better  end  result,  if  the  surgical  intervention  be 
delayed  until  the  clot  has  become  completely  organized. 

The  difficulty  in  these  cases  centers  about  the  diagnosis.  If  one  is 
willing  to  assume  full  responsibility  for  the  termination,  and  can  be  as- 
sured that  hemorrhage  has  ceased  and  will  not  recur,  a  waiting  plan  may 
be  adopted.  The  writer  feels  that,  so  far  as  his  own  experience  is  con- 
cerned, he  can  never  be  certain  as  to  these  essential  facts,  and  in  the  ab- 
sence of  that  certainty  he  feels  it  incumbent  upon  him,  in  the  best  interests 
of  the  patient,  to  ascertain,  by  direct  inspection,  the  true  state  of  affairs 
and  to  secure  torn  blood  vessels  against  any  possibility  of  recurring  hem- 
orrhage. 

The  Treatment  of  Advanced  Extra-Uterine  Pregnancy. — By 
advanced  extra-uterine  pregnancy  is  meant  those  cases  not  seen  until 
after  the  fifth  month,  the  fetus  being  alive  or  having  perished,  as  may  be. 
Here  the  management  of  the  placenta  becomes  the  factor  of  first  import- 
ance, together  with  the  fact  that  a  possible  infant  life  is  to  be  considered, 
as  well  as  that  of  the  mother. 

The  placenta  may  occupy  any  position  within  the  abdominal  cavity, 
although  it  is  most  commonly  found  firmly  attached  to  the  posterior  fold 
of  the  broad  ligament  and  the  floor  and  lateral  walls  of  the  pelvis,  the 
villi  dipping  deep  into  the  pelvic  vessels.  In  other  instances,  however, 
the  placenta  may  be  found  attached  to  the  omentum,  the  intestines  or  in- 
deed to  any  of  the  intraperitoneal  viscera.    In  such  case,  where  the  fetus 


174  EXTRA-UTERINE  PREGNANCY 

is  alive  and  the  placental  circulation  active,  the  removal  of  this  organ  may 
be  attended  by  absolutely  uncontrollable  hemorrhage. 

No  definite  technic  for  the  performance  of  an  operation  for  advanced 
ectopic  pregnancy  can  be  formulated,  since  each  case  is  a  law  unto  itself, 
but  certain  general  directions  will  be  found  valuable. 

The  incision  is  preferably  to  be  made  along  the  outer  border  of  the 
rectus  muscle  overlying  the  gestation  sac,  since  so  many  of  these  placentas 
are  found  under  and  between  the  folds  of  the  broad  ligament  that  the 
removal  of  the  fetus  and  placenta  may  be  accomplished  without  entering 
the  peritoneal  cavity,  a  matter  greatly  to  be  desired,  especially  if  the 
placenta  cannot  be  removed  at  the  time  of  operation. 

Having  reached  the  sac,  it  should  be  incised,  the  child  extracted  and 
the  cord  ligated  as  in  cesarean  section.  The  sac  should  then  be  examined 
in  great  detail,  in  order  to  ascertain  whether  it  be  feasible  to  attempt  liga- 
tion of  its  blood  supply  and  excision,  or  whether  the  attachment  to  great 
vessels  or  to  vascular  viscera  is  so  intimate  that  attempt  at  enucleation 
will  result  in  disaster. 

In  the  former  alternative,  careful  ligation  of  the  vessels  supplying 
the  placenta  should  be  performed,  before  attempts  at  its  removal  are 
instituted.  The  ligations  accomplished,  the  placenta  may  be  manually 
pulled  off  its  attachment,  bleeding  being  controlled  by  ligatures  and  pres- 
sure by  gauze  wrung  out  in  hot  saline  solution,  and  the  wound  closed 
without  drainage. 

Should  the  location  of  the  placenta  be  such  that  control  of  its  blood 
supply  seems  impracticable,  there  are  two  methods  for  its  management. 
First,  the  time  honored  plan  of  marsupialization,  stitching  the  edges  of 
the  gestation  sac  to  the  abdominal  wound  and  lightly  packing  the  cavity 
with  gauze.  The  gauze  packing  is  changed  at  forty-eight  hour  intervals 
and  the  separation  of  the  placenta  aided  by  gentle  traction.  In  the  course 
of  a  few  weeks  the  tissue  has  sloughed  out  and  there  remains  a  sinus 
of  varying  size,  which  usually  closes  spontaneously,  although  a  second 
operation  for  the  repair  of  the  abdominal  wall  may  be  required. 

The  second  plan,  recently  advocated  by  Beck,2  is  to  simply  leave  the 
placenta  in  situ  and  close  the  abdominal  wound  without  drainage,  depend- 
ing upon  the  absorption  power  of  the  peritoneum  for  the  subsequent 
removal  of  the  lesions.  To  test  this  principle,  Beck  placed  three  fifths  of  a 
500  grain  placenta,  removed  by  cesarean  section,  in  the  abdomen  of  a 
dog.  The  animal  promptly  recovered.  Two  months  later  its  abdomen 
was  reopened  and  no  trace  of  the  placenta  could  be  found.  In  Beck's 
statistics,  there  were  twelve  cases  in  which  this  procedure  was  adopted, 
from  1890  to  1919,  of  which  four  died,  a  mortality  of  33.3  per  cent 


TREATMENT  175 

during  the  same  period,  marsupialization  was  practiced  in  52  women,  22 
of  whom  died,  or  38.7  per  cent. 

While  these  figures  are  greatly  in  favor  of  leaving  the  placenta  for 
absorption,  they  are  subject  to  the  usual  destructive  criticism,  since  it  is 
not  stated  in  how  large  a  proportion  of  the  patient's  fruitless  attempts 
at  enucleation  had  been  made  before  it  was  decided  to  leave  the  placenta, 
which  had  been  found  impossible  of  removal,  with  the  consequent  in- 
fection and  hemorrhage. 

While  he  has  never  left  a  placenta  for  absorption,  and  is  therefore 
not  qualified  to  criticize  this  treatment,  the  writer  confesses  to  a  decided 
repugnance  to  leaving  so  large  a  mass  of  foreign  tissue  within  the  un- 
drained  peritoneal  cavity. 

In  a  consideration  of  the  treatment  of  advanced  ectopic  pregnancy 
from  the  standpoint  of  the  child,  two  questions  present  themselves :  first, 
whether  the  fetus  is  apt  to  have  suffered  some  arrest  of  development  which 
renders. its  postnatal  life  doubtful  or  impossible;  second,  whether  or  not 
the  maternal  risk  is  greatly  increased  by  permitting  the  pregnancy  to  con- 
tinue until  term  or  thereabouts. 

Briefly  put,  the  question  is,  what  is  the  best  time  to  interfere  in 
the  interests  of  the  child,  what  the  best  in  the  interests  of  the  mother, 
and  is  there  a  time  during  the  gestation  when  these  divergent  interests 
may  both  be  protected.  Beck  2  has  approached  this  problem  by  carefully 
collecting  case  reports  from  the  literature,  as  well  as  from  the  replies  to 
a  questionnaire  sent  to  over  200  obstetricians.  From  his  study  of  these 
cases,  Beck  concludes  that: 

1.  The  best  time  to  operate  is  during  the  sixth  or  the  seventh  month. 

2.  The  added  risk  in  waiting  for  a  well  developed  child  is  slight  up 
to  the  thirty-ninth  week. 

3.  The  danger  of  a  catastrophe  is  sufficiently  great  in  the  last  two 
weeks  to  warrant  interference  before  this  period  is  reached. 

In  the  interests  of  the  child  it  is  found  that  the  best  time  to  operate  is 
the  thirty-eighth  week,  more  infants  having  survived  at  this  period  than 
at  any  other.  This  may  be  explained  to  mean  that,  as  interference  is 
practiced  before  term,  the  child,  as  well  as  the  mother,  is  spared  the  dan- 
ger of  spurious  labor,  and  further,  that  the  fetus  is  subjected  to  greatly 
increased  pressure  during  the  last  two  weeks  of  pregnancy,  by  reason  of 
the  diminution  in  the  amount  of  the  liquor  amnii  at  this  time. 

Since  the  risk  in  waiting  for  the  thirty-eighth  week  is  slight  for  the 
mother,  and  since  this  is  the  time  of  election  for  the  child,  it  follows  that 
the  thirty-eighth  week  of  pregnancy  is  the  best  period  for  surgical  inter- 
vention from  the  standpoint  of  both  mother  and  child. 


176  EXTRA-UTERINE  PREGNANCY 

That  these  abdominal  children  are  worth  saving  is  beyond  a  doubt, 
Cragin  finding  two  normal  living  infants  in  his  four  cases,  while  Hors- 
ley's  statistics,  previously  quoted,  amply  confirm  this. 

The  Treatment  of  Advanced  Ectopic  Pregnancy  When  the 
Fetus  is  Known  to  Be  Dead. — Should  the  fetus  have  been  dead  for 
a  considerable  time,  immediate  removal  of  the  placenta  is  usually  possible, 
its  vascularity  having  markedly  decreased  and  a  partial  separation  of  the 
villi  from  their  site  of  implantation  having  taken  place.  If  the  fetus  is 
known  to  have  been  dead  but  a  short  time,  it  is  advisable  to  defer  opera- 
tion until  some  obliteration  of  the  maternal  blood  spaces  about  the  villi 
has  occurred,  since  the  enucleation  of  the  placenta  is  greatly  facilitated 
thereby.  During  the  month  or  six  weeks  of  waiting  for  the  separation 
to  take  place,  the  patient  should  be  under  constant  observation  in  a  hos- 
pital, in  order  that  immediate  operation  may  be  performed  in  the  event 
of  any  infection  of  the  gestation  sac  supervening,  as  evinced  by  an  ele- 
vation of  temperature  and  pulse  rate  and  an  increasing  leukocytosis. 

The  Treatment  of  Infected  and  Suppurative  Ectopic  Pregnancy. 
— Where  infection  is  present,  the  ideal  method  of  treatment  is  vaginal  in- 
cision, the  extraction  of  such  of  the  products  of  gestation  as  are  within 
reach,  and  the  establishment  and  maintenance  of  free  drainage.  Sup- 
puration is  the  only  condition  arising  in  connection  with  extra-uterine 
pregnancy,  in  which  the  vaginal  route  of  operation  is  indicated,  in  the 
opinion  of  the  writer,  who  feels  that  the  time  involved  and  the  trauma 
inflicted  are  far  less  and  the  completeness  of  the  operation  is  best  attained 
by  abdominal  attack  in  all  cases,  save  those  complicated  by  pus  formation. 

The  technic  of  vaginal  incision  is  so  well  understood  that  any  de- 
tailed description  would  be  out  of  place  here.  Suffice  it  to  say  that  the 
posterior  vaginal  fornix  is  the  point  of  attack,  and  the  incision  into  the 
abscess  cavity  is  to  be  of  sufficient  size  to  admit  of  thorough  digital  ex- 
ploration, in  order  to  extract  any  large  portions  of  the  fetal  body,  if 
such  be  present. 

Drainage  is  best  maintained  by  the  suturing  into  the  cavity  of  a  large 
sized  rubber  drainage  tube,  through  which  the  abscess  cavity  may  be 
flushed  with  Carrel-Dakin  solution,  or  other  antiseptic  agent,  at  the  option 
of  the  operator. 

The  Treatment  of  Hematocele. — The  same  general  views  obtain 
in  the  management  of  old  organized  blood  in  the  pelvis  as  are  held  with 
regard  to  the  treatment  of  advanced  ectopic  pregnancy.  So  long  as  no  in- 
fection is  present,  the  abdominal  route  is  advised,  since  intestinal  adhe- 
sions, usually  so  marked  in  other  cases,  can  best  be  dealt  with  under  the 


TREATMENT  177 

eye,  the  mass  can  be  much  more  thoroughly  enucleated,  and  the  danger  of 
traumatism  to  adjacent  structures  is  reduced  to  a  minimum.  When  com- 
plicated by  suppuration,  however,  hematocele  is  best  treated  by  simple 
vaginal  incision  and  drainage,  as  described  above. 

The  first  American  operation  for  the  relief  of  advanced  ectopic  preg- 
nancy by  the  vaginal  route  was  performed  by  Dr.  John  King  3  of  Edisto 
Island,  S.  C,  in  18 16,  when  a  full  term  child  was  removed  after  cutting 
through  the  posterior  vaginal  wall. 

Mortality  and  Prognosis. — The  hope  for  recovery  of  a  woman 
afflicted  with  ectopic  pregnancy  is  yearly  growing  greater,  and  the 
gynecologist  who  reviews  the  history  of  this  remarkable  lesion  must  com- 
plete his  surveys  with  intense  pride  and  gratification  that  the  labors  of 
his  predecessors  in  this  field  have  wrought  such  vast  improvement  in  re- 
sults. Consider  Parry's  statistics  of  1876,  when  among  500  cases  386 
perished  of  this  lesion. 

In  1 91 8  in  Philadelphia,  there  were  169  such  patients  admitted  to 
hospitals,  of  whom  thirteen  died,  or  y.j  per  cent.  These  figures  contem- 
plate all  cases — those  admitted  to  hospital  when  already  moribund,  as  well 
as  the  more  favorable  types. 

In  Farrar's  series  of  309  cases,  there  were  three  deaths,  or  .97  per  cent. 
In  P.  F.  Williams'  series  of  147  cases,  death  occurred  four  times,  a  mor- 
tality of  2.J  per  cent.  Of  Oastler's  106  cases,  seven  died,  or  6.5  per  cent. 
The  writer  has  studied  307  cases  with  eight  deaths,  or  2.6  per  cent. 

On  the  whole,  then,  it  may  be  concluded  that  the  average  mortality 
in  a  well  conducted  clinic  will  be  4  per  cent  or  under,  and  it  is  the  firm 
belief  of  the  writer  that  if  every  woman  brought  to  a  hospital  with  a  cor- 
rect diagnosis  of  ruptured  ectopic  pregnancy  be  subjected  to  immediate 
operation,  without  regard  to  her  condition,  the  mortality  will  be  still 
further  reduced.  Two  of  the  writer's  eight  deaths  were  a  direct  result 
of  his  lack  of  courage  in  operating  upon  moribund  women,  and  since  this 
time,  now  four  years  ago,  not  one  case  has  perished. 

It  has  been  said  in  high  places  that  there  is  no  excuse  for  the  exist- 
ence of  gynecology  as  a  surgical  specialty,  but  to  him  who  has  read  this 
book,  the  question  is  left,  as  to  whether  or  not  a  branch  of  medicine  which 
has  within  a  half  century  reduced  the  mortality  of  so  dreadful  an  acci- 
dent as  the  rupture  of  a  gravid  tube,  from  80  per  cent  to  4  per  cent,  has 
not  justified  its  existence  in  full. 


178  EXTRA-UTERINE  PREGNANCY 


LITERATURE 


1.  Cragin,  E.  B.    The  Treatment  of  Ectopic  Gestation.    Surg.  Gyn. 

Obst.     1912.     14:276. 

2.  Beck,  A.  C.     Treatment  of  Extra-Uterine  Pregnancy  After,  the 

Fifth  Month.    Jr.  Am.  Med.  A.    1919.    73  1962. 

3.  King,  J.    Am.  Analysis  of  the  Subject  of  Extra-Uterine  Gestation. 

Munich,  18 18.    p.  176.    Quoted  by  J.  W.  Williams. 


INDEX 


Abderhalden  reaction  in  ectopic  preg- 
nancy,  126 

Abdominal  lesions,  not  connected  with 
the  ectopic  pregnancy  when  (un- 
der operation,  management  of, 
168 

Abdominal  pregnancy,  complicated  by 
eclampsia,   no 

— ■  extraperitoneal,  82 

—  following  normal   uterine   implanta- 

tion, after  rupture  of  uterus,  83 

—  primary,  causes  of,  31 

—  secondary,    following   tubal    rupture 

or  abortion,  42 

—  secondary      to       primary      ovarian 

pregnancy,  44 

—  symptomatology    and    diagnosis    of, 

146 

—  termination  of,  82 

Abdominal  symptoms  in  extra-uterine 
pregnancy,   133 

Adenomyoma  of  the  uterus,  ectopic 
pregnancy  occurring  in  gland 
spaces  of,  112 

Adhesions,  peritubal,  causing  extra- 
uterine pregnancy,  23 

Adipocere,  diagnosis  of,  147 

Amenorrhea,  in  ectopic  pregnancy, 
122,  123 

Anemia,  post-operative  treatment  of, 
171,  172 

Anteflexion  of  uterus,  132 

Apoplexy,  ovarian,   113 

Appendicitis,  case  of,  in  combination 
with  an  unruptured  tubal  preg- 
nancy, 109 


Blood  picture,  in  extra-uterine  preg- 
nancy, 133 

Blood  pressure  in  extra-uterine  preg- 
nancy, 134 

Breast  changes,  in  ectopic  pregnancy, 

125 
Broad  ligament  pregnancy,  39,  40 


Cardiac  failure,  post-operative  treat- 
ment of,  172 

Casts,  decidual,  of  extra-uterine  preg- 
nancy, See  Decidual  casts. 

— ■ — of  membranous  dysmenorrhea,  67 

—  menstrual,  67 

Cervical  pregnancy,  criteria  of,  in 

—  definition   and   classification   of,    in 

—  frequency  of,  in 

— 'primary  and  secondary,  in 

—  terminations  of,  in 

Cervix,  softening  of,  in  ectopic  preg- 
nancy,  125 

Cholecystitis,  differentiated  from  ec- 
topic pregnancy,   155 

Chorioepithelioma  of  tubes,  resulting 
from  tubal  pregnancy,  84 

Combined  intra-  and  extra-uterine 
pregnancy,  19,  108 

Cornual  pregnancy,  See  Interstitial 


Decidua,  formation  of,  from  extra- 
uterine pregnancy,  85 

—  —  in  tubes,  53,  54 

—  importance  of,  in  producing  a  nor- 

mal implantation,  88 
— 'passage  of,  in  diagnosis  of  ectopic 
pregnancy,  132 

—  use  of  term,  54 

Decidua  vera,  development  of,  in 
uterus,  due  to  extra-uterine  preg- 
nancy, 62 

—  relation   of    decidual    casts    and,    to 

extra-uterine  pregnancy,  63 
Decidual  casts,  of  extra-uterine  preg- 
nancy, description  of,  66 

—  — -diagnostic  errors   from  examina- 

tion of,  65 
— ■ — 'passage  of,  in  diagnosis  of  ectopic 
pregnancy,  64,   132 

—  of    membranous    dysmenorrhea,    de- 

scription of,  6y 
Decidual     masses     in     the     omentum, 
etiology  of,  85 


179 


i8o 


INDEX 


Decidual  reaction  in  tubes,  as  cause 
of  extra-uterine  pregnancy,  25,  50 

Ecchyesis,  See  Extra-uterine  Preg- 
nancy 

Eclampsia,  complicating  extra-uterine 
pregnancy,    no 

Ectopic  pregnancy,  See  Extra-uterine 
Pregnancy 

Electricity,  in  treatment  of  ectopic  ges- 
tation, 15 

Embryo,  death  of,  with  formation  of 
tubal  mole,  as  termination  of 
ovarian  pregnancy,  35 

—  fate  of,  in  extra-uterine  pregnancy, 

87 
■ — -normal  and  pathological,  88 

—  percentage  that  goes  on  to  full  term, 

88 
Extra-uterine     pregnancy,     abdominal, 

complicated  by  eclampsia,   no 

extraperitoneal,   82 

— ■ — following  normal  implantation  of 

ovum,  after  rupture  of  uterus,  83 

primary,  causes  of,  31 

'secondary,  42 

secondary     to     primary     ovarian 

pregnancy,  44 
— ■  —  symptomatology  and  diagnosis  of, 

146 
termination  of,  82 

—  advanced,  common  forms  of,  80 
pathology  of,   79 

placental  attachment  in,  82 

— i  —  question  as  to  whether  fetal  de- 
velopment may  continue  uninter- 
rupted, 81 

treatment  of,  173 

'when    fetus    is    known    to    be 

dead,  176 

—  age  incidence  of,  19 

—  anatomicopathological     groups     for 

diagnosis   of,    119 

—  before  any  bleeding  takes  place  into 

the  tubal  wall  or  the  peritoneal 
cavity,  symptomatology  of  and  dif- 
ficulties of  diagnosis,  120,  121 

—  with  beginning  tubal  abortion  or  a 

minute  rupture,  permitting  a  mi- 
nute quantity  of  free  blood  to  come 
in  contact  with  peritoneal  sur- 
faces, diagnosis  and  symptomatol- 
ogy of,  121 


Extra-uterine  pregnancy,  bimanual  ex- 
aminations for,  importance  of  care 
and  gentleness  in,  132 

—  broad-ligament,  39,  40 

— ■  causes  of,  accessory  tubes,  25 

anomalies  of  tubal  lumen,  25 

constriction  resulting  from  pres- 
sure of  a  tumor  of  neighboring 
structures,  24 

decidual    reaction    in    tubes,    25, 

50 

■difficulties  in  arriving  at,  22 

— ■  —  external  migration  of  the  ovum, 

27,  51 

gonorrhea,  24 

— ■  —  identical  in  both  tubes,   101 

— ■  —  inflammatory,  30 

— ■  —  interference,  23 

— ■ — of  interstitial  pregnancy,  70 

— ■  —  mechanical  or  postinflammatory 
obstruction  to    ova,   29,    50 

monstrous      or      deformed      ova, 

29 

— ■ — 'obstruction  of  tubal  lumen  from 
within,  24 

■  obstruction   of  tubal  lumen  from 

without,  23 

— ■ — of  ovarian  pregnancy,  31 

'  peritubal  adhesions,  23 

■  pre-existing  pelvic  disease,  129 

— ■  —  previous  operations,  130 

— ■  — ■  previous  conservative  gynecolog- 
ical operations,  23 

of  primary   abdominal,   31 

—  —  salpingitis,  24 

— ■ — ■  Schil's  theory,  failure  of  un- 
striped  muscle  fibers  of  tube  to 
contract,  29 

secretion    by   tube    of    substances 

toxic  to  ovum,  impairing  its  vital- 
ity and  ability  to  progress, 
29 

sterility,  127 

'Summing   up    of,   29 

■  tubal  polyps,  28,  50 

—  ■ — -tumors  of  the  tube,  27 

—  cervical,   in 
criteria  of,   ill 

'definition     and    classification     of, 

ill 
— ■ — frequency  of,   111 

■  primary   and   secondary,    in 

— ■ — -terminations  of,   in 


INDEX 


181 


Extra-uterine  pregnancy,  co-existing 
with  intra-uterine,   19,   108 

— -  comparative  results  with  normal 
and  with  pathological  embryos, 
88 

—  complicated,   109 

diagnosis  of,  147 

by  eclampsia,  HO 

by  fibroid  tumors  of  uterus,  109 

by  inflammatory  disease,  109 

by  toxemias  of  pregnancy,  no 

—  cornual,  See  Interstitial 

—  decidual  cast  of,  description  of,  66 
diagnostic  errors  from  examina- 
tion of,  65 

passage     of,     in     diagnosis,     64, 

132 

—  definition  of,   17 

—  diagnosis   of,   abdominal  pregnancy, 

146 

adipocere,  147 

amenorrhea,  122,  123 

anatomicopathological  groups  for, 

119 
in    beginning    tubal    abortion    or 

with  a  minute  rupture,  permitting 

a  minute  quantity  of  free  blood  to 

come    in    contact   with    peritoneal 

surfaces,  121 
in  cases  without  any  leakage  of 

blood    into   the    abdominal    cavity, 

difficulties  and  symptomatology  of, 

120 
■  from  character  of  menstrual  flow, 

122,  123 

in  complicated  cases,  147 

concomitant   signs   of  pregnancy, 

124 

Abderhalden  reaction,  126 

anteflexion     of     uterus,      126, 

132 

breast  changes,  125 

■  —  enlargement    of    uterus,     125, 

132 

frequency  of  urination,  126 

increased    pigmentation,    125 

morning  nausea  and  vomiting, 

125 

softening  of  cervix  and  en- 
largement of  uterus,  125,  132 

difficulties  of,  118,  119 

— ■  —  evidences  upon  which  correct 
conclusion  may  be  reached,  121 


Extra-uterine  pregnancy,  diagnosis  of, 

findings    on    general    examination 

of  patient,  131 
— ■ — ■  —  abdominal,  133 

— ■ blood  picture,  133 

blood  pressure,  134 

— • — ■ — -enlargement     of     uterus,     125, 

132 

— ■ -Hegar's  sign,  132 

— ■ — ■ — -passage  of  decidua  or  decidual 

casts,  132 

■ —  pelvic  mass,  131 

— pulse,  133 

— ■ temperature,    133 

first  steps  in,  118 

— ■ — -with  frank  rupture  of  sac  or  tubal 

abortion,  136 

— asthenic  group,  136 

— ' — ■  —  sthenic  group,  138 

— ■ — -hemorrhage,    character    of,    122- 

124 
-histological,  157 

—  — -history,   122 

—  — ■  importance  of  care   in  bimanual 

examinations,  132 

—  —  interstitial,  143 

— -long  existing  and  untreated  ectopic 
gestation,  141 

■  —  hematocele,  141 

■  —  lithopedion  or  adipocere,   147 

— ■ — ■  —  tubal  mole,   142,  143 

■  —  other  than  tubal,  143 

'Ovarian  pregnancy,  145 

-pain  of  interstitial  forms  in  con- 
tradistinction to  that  of  tubal, 
143. 

pain  in  pelvis  as  most  important 

and  constant  sign  of,  126 

by  palpation,  121 

previous  history,  127 

— ■ — ■  —  general  health  and  medical  his- 
tory of  patient,  130 

-pre-existing  pelvic  disease,  129 

—  — ■  —  previous  operations,  130 
—  sterility,  127 

tubal  mole,  141 

—  differential  diagnosis  of,  from  acute 

salpingitis,  151 

general  divisions   for,   119 

from   hemorrhage    from   tube   or 

ovary,    not    in    relation    to    preg- 
nancy, 148 
from  ovarian  cysts,  152 


182 


INDEX 


Extra-uterine  pregnancy,  differential 
diagnosis  of,  from  retroversion  of 
the  normally  pregnant  uterus,  153 

— .  —  from  ruptured  gastric  ulcer,  renal 
colic,  cholecystitis,  etc.,  155 

from  uterine  abortion,  148 

— ,  —  various  forms  indistinguishable 
after  rupture,  145 

— 'extraperitoneal  abdominal,  82 

—  fate  of  embryo  in,  87 

—  fate  of  fetus  in,  summarization  of, 

96 

—  fetuses   that   develop    to    full   term, 

deformities  of,  88,  89 

—  —  normal,  89 

—  frequency  of,  age  incidence,  19 

'Constantly  increasing,  17 

—  explanation  of,  18 

figures  showing  absolute  relation 

of  extra-  to  intra-uterine  preg- 
nancy, 18 

of  interstitial,  69 

.old  statistics,  17 

— •  —  of  ovarian  cases,  83 

race  incidence,  19 

.relative,  of  various  forms,  21 

—  frequency  of  recurrence  of,   101 

—  histological    diagnosis    of,    157 

—  history    of,     Bain's     operation,     for 

long-retained  fetus    (1540),  5 

Campbell's  Memoir  (1842),  11 

'Case  of  Albucasis  (nth  century), 

1,  2 
— .  —  case  of  Bard,  America  (1759),  9 

'case  of  Baynham,  10 

case  of  Calvo,  France,  1714,  6 

case  of  Cornax  ( 16th  century) ,  4 

case  of  Felix  Platerus  (1594),  7 

case  of  Mauriceau   (1669),  7 

case  of  Nufer  (1500),  4 

case  of  Primrose  (1594),  6 

— .  —  case  of  Riolan  (1604),  6 
case  of  Schmitt,  interstitial  preg- 
nancy, 10 
—  —  cases  of,  in  America,  from  1791 

to  1846,  10 
first      absolutely      definite      case 

(1594),  6 

first  case  of  tubal  gestation  with 

rupture,  1604,  6 

first  recorded  case  (nth  cen- 
tury), 1 

in   America    (1759),   9 


Extra-uterine  pregnancy,  history  of, 
increased  interest  in,  in  America, 
from  1846,  10 

-lithopedion  of  Sens  (16th  cen- 
tury), 3 

— > —  monograph  of  Dezeimeris  (1837), 
10 

— ■ — 'Ovarian  pregnancy,   12 

— ■ — 'Parry's  work   (1876),  11 

Pierre  Dionis  on  (1718),  9 

Tait's  work,  12 

— ■ — 'Unknown  to  ancients,  I 

'varieties  of,  10 

— ■ — 'Werth's  studies,  12 

—  history  of  treatment   for,    12 

— ■ — 'in  early  rupture  of  tubal  preg- 
nancy, 12 

— ■ — 'electricity,  15 

gastrotomy,  14 

.laparotomy     dating     from     1500, 

12 

— 1  —  Parry  on,  12 

— ■  infected  and  suppurative  cases  of, 
treatment  of,  176 

— 'interstitial,  diagnosis  of,  143 

etiology  of,  70 

— ■  —  first  recorded  case  of,  10 

— ■  —  frequency  of,  69 

groups  of,  70 

— ■  —  illustrative  cases  of,  71 

— ■  — ■  pain  of,  in  contradistinction  to 
that  of  tubal   pregnancy,    143 

— 1  —  pathology  of,  69 

— • — 'rupture  of,  143 

—  — ■  symptomatology  and  diagnosis  of, 

143 
terminations  of,  70 

—  —  —  by    gradual    growth    of    fetus 

into  uterine  cavity,  41 
treatment  of,  172 

—  intraligamentary,   44 

—  mortality  of,  177 

—  onset  of,  general  form  of,  134 

—  ovarian,  causes  of,  31 
— 1  —  diagnosis  of,  145 
duration  of,  76 

first  case  diagnosed  as,  12 

frequency  of,  73 

pathology  of,  73 

placentation  in,  75 

rupture  of,  77 

terminations  of,  34 

treatment  of,  173 


INDEX 


183 


Extra-uterine        pregnancy,        ovario- 
abdominal,  44 

—  placentation    in   ovarian    pregnancy, 

—  primary  abdominal,  causes  of,  31 

—  prognosis  of,  177 

—  question  of  removal  of  non-pregnant 

tube  as  routine  procedure  in  opera- 
tion for,  102 

—  race  incidence  of,  19 

—  recurrent,  cause  of,  102 

frequency  of,  101 

interesting  case  of,  103 

for  third  time,  instances  of,  103 

—  relation  of  uterine  decidua  and  de- 

cidual casts  to,  63 

—  repetition  of,  19 

—  results  of  fetal  death,  without  sur- 

gical removal,  lithokelyphopedion, 

92 

lithokelyphos,  92 

lithopedion,  91 

skeletonization,  89 

suppuration,  89 

—  ruptured,  diagnosis  of,  136 

due    to     bimanual     examinations 

without  sufficient  care,  132 
simulated    by    hemorrhage    from 

ovary  or  tube,  113 
simulated    by    hemorrhage    from 

rupture   of   an   apparently  normal 

graafian  follicle,  113 

—  ruptured  tubal,  delayed  surgical  in- 

tervention, 15 

electricity  in  treatment  of,  15 

first  American  operation  for,  15 

gastrotomy  in  treatment  of,  14 

hemorrhage   from  ovary  or  tube 

simulating,  113 

history  of  treatment  for,  12 

immediate    laparotomy    the    rule 

today,  16 
.Parry's  work  on,  12 

—  secondary  abdominal,  42 

—  symptomatology  of,   abdominal,   133 

of  abdominal  pregnancy,  146 

amenorrhea,  122,  123 

in    beginning   tubal    abortion    or 

with  a  minute  rupture,  permitting 
a  minute  quantity  of  free  blood  to 
come  in  contact  with  peritoneal 
surfaces,  121 

blood  picture,  133 


Extra-uterine  pregnancy,  symptom- 
atology  of,   blood  pressure,    134 

.in  cases  without  any  leakage   of 

blood  into  abdominal  cavity, 
120 

—  —  character  of  menstrual  flow,  122, 

123 
— ■  —  concomitant   signs   of  pregnancy, 

124 

Abderhalden  reaction,  126 

breast  changes,   125 

.  —  enlargement  of  uterus,  132 

— . ■  frequency  of  urination,  126 

— ■ increased  anteflexion  of  uterus, 

126 

increased  pigmentation,  125 

morning  nausea  and  vomiting, 

125 

softening  of  cervix  and  en- 
largement of  uterus,  125 

— .  —  evidences  upon  which  a  correct 
conclusion  may  be  reached,  121 

— . —  with  frank  rupture  of  sac  or  tubal 
abortion,  136 

generally  one  of  a  subacute  dis- 
ease rather  than  one  of  fulminant 
type,  134 

hemorrhage,    character    of,    122- 

124 

of  interstitial  forms,  143 

in    long    existing    and    untreated 

cases,  hematocelej  tubal  mole, 
lithopedion  formation,  etc.,  141 

pain  in  pelvis  most  important  and 

constant  sign,  126 

— ■  —  passage  of  decidua  or  decidual 
casts,  132 

pelvic  mass,  131 

—  —pulse,  133 
.temperature,  133 

—  terminations  of,  135 

■  in  abdominal  cases,  82 

of  cervical,  in 

by  death  of  embryo  with  the  for- 
mation of  tubal  mole,  35 

end  results,  hematocele,  44,  77 

'resorption  of  products  of  ges- 
tation, 44 

— . 'terminal  changes,  46 

• —  tubal  mole,  44 

gradual  growth  of  fetus  into  uter- 
ine cavity,  in  cases  of  interstitial 
pregnancy,  41 


184 


INDEX 


Extra-uterine  pregnancy,  termination 
of,  growth  and  development  of 
fetus  to  full  term,  while  still  con- 
fined in  tube,  41 

hematocele,  44,  yy 

in  interstitial  cases,  70 

primary,  33 

by  rupture  of  the  pregnant  tube, 

37 
between  the  folds  of  the  broad 

ligament,  39 

into  the  peritoneal  cavity,  37 

secondary,   abdominal   pregnancy, 

secondary      to      primary     ovarian 

pregnancy,  44 

intraligamentary  pregnancy,  44 

■  —  ovario  -  abdominal     pregnancy, 

44 

secondary  abdominal  preg- 
nancy, 43 

tubo-abdominal   pregnancy,   42 

tubo-ovarian  pregnancy,  43 

— ■  —  by  tubal  abortion,  35 

tubal  rupture,  57 

— 'tissue  changes  resulting  from,  84 

chorioepithelioma,  84 

— •  —  decidua  formation,  85 

— 'treatment  of,  in  advanced  cases,  173 

when    fetus    is    known    to    be 

dead,  176 

after  rupture  of  sac  or  tubal  abor- 
tion, with  intra-abdominal  hemor- 
rhage, 162 

— ■  —  after  rupture,  when  surgical 
facilities  are  available,  closure  of 
the  incision,  168 

■  —  expectant    plan    of    treatment, 

163,  164 

indications  for  delayed  sur- 
gical intervention,  173 

in  interstitial  cases,  172 

management      of      abdominal 

lesions  not  connected  with  the  ec- 
topic pregnancy,   168 

— ■ management    of    the    affected 

tube,  166 

management  of  free  blood  and 

clots  in  the  abdominal  cavity,  166 

management  of  the  remaining 

tube,  167 

■ operation,  regardless  of  condi- 
tion of  patient,  163,  165 

operative  procedure,  165 


Extra-uterine  pregnancy,  treatment  of, 
after  rupture,  in  ovarian  cases,  173 

postoperative,  171 

—  technic  of  the  laparotomy,  169 

two  indices  of  patient's  condi- 
tion, 165 

— "vicious  catch  phrases"  used  in 

determining,   164 

— ■ — ■  before  rupture  has  occurred,  161 

by  electricity,  15 

by  gastrotomy,  14 

for  hematocele,  176 

history  of,  See  History  of  treat- 
ment of 

in  infected  and  suppurative  cases, 

176 

— ■  —  management  of  certain  phases  of 
the  condition,  161 

—  triplet,  106 

—  case  of  Mauriceau  (1669),  7 

—  —  case  of  Riolan  (1604),  6 

causes  of,  external  migration  of 

ovum,  51 
mechanical     or    postinflamma- 
tory obstruction  to  ova,  50 

Pierre  Dionis  on   (1718),  9 

Regnus  Graaf  and  others,  8 

comparative   results  with  normal 

and  with  pathological  embryos,  88 

■  complicated,  109 

decidua  in,  formation  of,  54 

decidual  reaction  causing,  52 

first  reported  case  of  (1604),  6 

history  of  treatment  of,  12 

mode  of  implantation  of  ovum  in 

tubes,  52 
— ■ — 'pain  of  interstitial  in  contradis- 
tinction to  that  of,  143 

—  — ■  placentation  in,  55 

process  of,  in  advanced  cases,  59 

See    also    Tubal    Pregnancy   and 

Tubal  Rupture 

—  tubo-abdominal,  42 

—  tubo-ovarian,  43 

—  twin,  104 

diagnosis  of,  105 

— 1 — 'unilateral,  characteristic  case  of, 

105 

—  unique  forms  of,  cervical,  in 
in  gland  spaces  of  an  adenomyo- 

ma  of  the  uterus,  112 

—  uterine    changes    produced    by,    de- 

velopment of  decidua  vera,  62 


INDEX 


185 


Extra-uterine  pregnancy,  uterine 
changes  produced  by,  increased 
size,  62 

involution,  62,  63 

uterine  bleeding,  62 

—  varieties   of,    10,    17,    19 

Kelly's  table  showing  changes  of 

primary  to  secondary  forms,  21 

primary,  20 

relative  frequency  of,  21 

secondary,  20 

Fallopian  tubes,  accessory,  causing 
extra-uterine  pregnancy,  25 

—  action  of  trophoblast,  54 

—  active  peristaltic  powers  of  muscu- 

lar layers  of,  48 

—  anatomy  of,  47 

—  boundaries  of  gestation  sac,  55 

—  chorioepithelioma  of,  resulting  from 

tubal  pregnancy,  84 

—  decidua  in,  formation  of,  53,  54 

—  decidual  reaction  in,  as  cause  of  ex- 

tra-uterine pregnancy,  25,  50 

—  direction    of    current    produced    by 

cilia  of,  47 

—  implantation  of  ovum  in,  always  ac- 

companied by  excessive  amount  of 

hemorrhage,  54 

centrifugal,  54 

columnar,  53 

intercolumnar,  54 

mode  of,  52 

resulting  processes,  56 

—  place   of   meeting   in,   of   spermato- 

zoon and  ovum,  53 

—  processes  of  infection  in,  48 

—  situation  of,  47 

—  susceptibility  of  mucosa   of,  to  in- 

vasion  and    damage    by    infective 
processes,  48 

—  trophoblast  cells,  55 

—  tumors     of,     causing     extra-uterine 

pregnancy,  27,  50 
Fetuses  in  extra-uterine  pregnancy,  de- 
formities of,  88 

—  fate  of,  96 

—  normal,  89 

—  results  of  death  of,  without  surgical 

removal,  lithokelyphopedion,  92,  93 
lithokelyphos,  92 

—  —  lithopedion,  91 
skeletonization,  89 


Fetuses  in  extra-uterine  pregnancy,  re- 
sults of  death  of,  without  surgical 
removal,  suppuration,  89 

—  summarization  of  fate  of,  96 
Fibrinoid  substance,  formation  of,  54 
Fibroid  tumors  of  uterus,  complicating 

tubal  pregnancy,   109 
Follicular  hemorrhage,  113 

—  cause  of,  115 

Gastric  ulcer,  ruptured,  differentiated 
from  ectopic  pregnancy,  155 

Gastrotomy,  for  ruptured  tubal  preg- 
nancy, history  of,  14 

Gestation  sac,  boundaries  of,  in  tubes, 
55 

Gonorrhea,  causing  extra-uterine  preg- 
nancy, 24 

Hegar's  sign,  132 

Hematinemia,    as    diagnostic    sign    of 

ruptured  ectopic  pregnancy,  138 
Hematocele,  definition  of,  78 

—  etiology  of,  77 

—  infected,  45 

—  pathology  of,  jy 

—  real  gravity  of,  79 

—  resulting    from    extra-uterine   preg- 

nancy, 44 

—  secondary  rupture  of,  79 

—  size  of,  78 

—  solitary,  45 

—  symptomatology  and  diagnosis,   141 

—  treatment  of,  176 

Hematoma,  ovarian,  113 

Hemorrhage,  of  extra-uterine  preg- 
nancy, amount  of,  in  tubal  abor- 
tion, 61,  62 

character  of,  122-124 

—  from  graafian  follicle,  115 

apparently  normal,  113 

^causes  of,  115 

—  from  ovary,  causes  of,  113 

diagnosis  of  cause  of,  115 

occurrence  of,  113 

pathology  of,  115 

from    ovary   or   tube,    simulating 

ruptured  ectopic  pregnancy,  113 

—  relative  amount  of,  in  cases  of  tubal 

rupture  and  tubal  abortion,  39 

—  from  tube,  causes  and  occurrence  of, 
•     114 

diagnosis  of  cause  of,  115 


1 86 


INDEX 


Inflammatory      disease,      complicating 

extra-uterine   pregnancy,   109 
Interstitial   pregnancy,   diagnosis   of, 

143 

—  etiology  of,  70 

—  first  recorded  case  of,  10 

—  frequency  of,  69 
relative,  70 

—  groups  of,  70 

—  illustrative  cases  of,  71,  72.,  143 

—  pain  of,  in  contradistinction  to  that 

of  tubal  pregnancy,  143 

—  pathology  of,  69 

—  rupture  of,  143 

—  symptomatology    and    diagnosis    of, 

143 

—  terminations  of,  70 

by  gradual  growth  of  fetus  into 

the  uterine  cavity,  41 

—  treatment  of,  172 
Intraligamentary  pregnancy,  44 

Jaundice,  as  diagnostic  sign  of  rup- 
tured ectopic  pregnancy,  138 

Laparotomy,  for  ruptured  ectopic 
pregnancy,  history  of,  from  1500, 
12 

— ■  —  technic  of,  169 

Lithopedion,  age  of,  93 

—  definition  of,  91 

—  diagnosis  of,  147 

—  frequency  of,  92 

—  length  of  time  carried,  92 

—  size  of,  93 

—  typical  case  of  (Maier's),  95 

—  ultimate  result  of  formation  of,  93 
Lithokelyphopedion,  92 

—  genesis  of,  93 

—  typical  case  of,  94 
Lithokelyphos,  92 

Membranous  dysmenorrhea,  decidual 
cast  of,  description  of,  67 

Menstrual  casts,  description  of,  67 

Menstrual  flow,  diagnosis  of  ectopic 
pregnancy  from  character  of,  122, 
123 

Morning  nausea  and  vomiting,  in  ec- 
topic pregnancy,  125 

Nausea  and  vomiting  in  ectopic  preg- 
nancy, 125 


Ovarian  apoplexy,  113 
Ovarian  cysts,  differentiated  from  ec- 
topic gestation,  ruptured,  152 
Ovarian  hematoma,  113 
Ovarian  hemorrhage,  causes  of,  113 

—  diagnosis  of  cause  of,  115 

—  occurrence  of,  113 

—  pathology  of,  115 

—  simulating    ruptured    ectopic    preg- 

nancy, 113 
Ovarian  pregnancy,  causes  of,  31 
— ■  diagnosis  of,  145 
— -  duration  of,  76 

—  first  case  diagnosed  as,  12 
— >  frequency  of,  73 

— 'pathology  of,  73 

— *  placentation  in,  75 

— -f  rupture  of,  77 

—^terminations  of,  34 

death  of  embryo  with  the  forma- 
tion of  tubal  mole,  35 

by  resorption  of  the  ovum,  34 

secondary,   abdominal  pregnancy, 

secondary  to  primary  ovarian  preg- 
nancy, 44 

ovario-abdominal  pregnancy,  44 

tubal  abortion,  35 

—  treatment  of,  173 

Ovarian  rupture,   followed  by  ovario- 
abdominal  pregnancy,  44 
Ovario-abdominal  pregnancy,  44 
Ovum,  external  migration  of,  51 
— '  —  causing  extra-uterine  pregnancy, 
27 

—  implantation  of,  in  tubes,  results  of, 

56 
always  accompanied  by  excessive 

amount  of  hemorrhage,  54 

centrifugal,  54 

columnar,  53 

intercolumnar,  54 

mode  of,  52 

—  mechanical  arrest  of,  causing  extra- 

uterine pregnancy,  29,  30 

—  monstrous  or  deformed,  causing  ex- 

tra-uterine pregnancy,  29 

—  normal  uterine  implantation  of,  fol- 

lowed by  rupture  of  uterus  and  ab- 
dominal pregnancy,  83 

—  place    of   meeting   of   spermatozoon 

and,  53 

—  resorption    of,     as    termination    of 

ovarian  pregnancy,  34 


INDEX 


187 


Pain,  of  interstitial  pregnancy,  in  con- 
tradistinction to  that  of  tubal,  143 

—  in  pelvis,  most  important  and  con- 

stant sign  of  ectopic  pregnancy, 
126 

Palpation  in  diagnosis  of  extra-uterine 
pregnancy,  121 

Pelvic  mass,  in  extra-uterine  preg- 
nancy, 131 

Peritubal  adhesions,  causing  extra-uter- 
ine pregnancy,  23 

Pigmentation,  increased,  in  ectopic 
pregnancy,  125 

Placentation,  in  ovarian  pregnancy,  75 

—  in  tubal  pregnancy,  55 
Pseudo  decidua,  76 


Renal  colic,  differentiated  from  ectopic 
pregnancy,  155 

Retroversion  of  the  uterus,  normally 
pregnant,  differentiated  from  ec- 
topic gestation,  153 

Ruptured  ectopic  pregnancy,  diagnosis 
of,  136 

—  due  to  bimanual  examinations  with- 

out sufficient  care,  132 

—  electricity  in  treatment  of,  15 

—  first  American  operation  for,  15 

—  gastrotomy  in  treatment  of,  14 

—  hemorrhage    from    ovary    or    tube 

simulating,  113 

—  hemorrhage  from  rupture  of  an  ap- 

parently  normal   graafian   follicle, 

113 

—  Parry's  work  on,  12 

—  treatment  of,  162 

— '  —  immediate  laparotomy  the  rule  to- 
day, 16 
Ruptured  interstitial  pregnancy,  143 
Ruptured  ovarian  pregnancy,  JJ 

—  followed  by  ovario-abdominal  preg- 

nancy, 44 


Salpingitis,   acute,   differentiated   from 

ectopic  gestation,  151 
—  causing  extra-uterine  pregnancy,  24 
Shock,  postoperative  treatment  of,  171 
Spermatozoon,    place    of    meeting    of 

ovum  and,  53 
Sterility,   history  of,   in   ectopic   preg- 
nancy, 127 


Temperature  in  extra-uterine  preg- 
nancy, 133 

Tissue  changes  resulting  from  extra- 
uterine pregnancy,  chorioepithe- 
lioma,  84 

—  decidua  formation,  85 

Toxemias   of  pregnancy,   complicating 

extra-uterine  pregnancy,  no 
Triplet  tubal  pregnancy,  106 
Trophoblast,  action  of,  54 

—  cells  of,  55 

Tubal  abortion,  amount  of  hemorrhage 
in,  as  compared  with  tubal  rupture, 

39 

—  complete,  61 

—  due  to  rupture,  57 

—  followed    by    secondary    abdominal 

pregnancy,  42 

—  incomplete,  62 

—  relative  frequency  of  tubal  rupture 

and,  37 
Tubal   abortion,   similarity  of,   to   rup- 
ture of  tube,  37 

—  as    termination    of    ovarian    preg- 

nancy, 35 

— 'treatment  of,  162 

Tubal  hemorrhage,  causes  and  occur- 
rence of,  114 

—  diagnosis  of  cause  of,  115 

—  simulating    ruptured    ectopic    preg- 

nancy, 113 
Tubal  lumen,  anomalies  of,  25 

—  obstruction  of,  from  within,  24 
from  without,  23 

Tubal  mole,  due  to  rupture,  58 

—  resulting  from  death  of  embryo,  35 

—  symptomatology    and    diagnosis    of, 

141 
Tubal     polyps,     causing    extra-uterine 

pregnancy,  28 
Tubal   pregnancy,   case   of   Mauriceau 

(1669),  7 

—  case  of  Riolan  (1604),  6 

— -causes    of,    external    migration    of 

ovum,  51 
^mechanical    or    postinflammatory 

obstruction  to  ova,  50 

Pierre  Dionis  on  (1718),  9 

'Regnus  Graaf  and  others,  8 

—  comparative  results  with  normal  and 

with  pathological  embryos,  88 

—  complicated,  109 

by  fibroid  tumors  of  uterus,  109 


INDEX 


Tubal  pregnancy,  decidua  in,  forma- 
tion of,  54 

—  decidual  reaction  causing,  50 

—  first  reported  case  of  (1604),  6 

—  history  of  treatment  of,  12 

—  mode   of   implantation   of   ovum   in 

tubes,  52 

—  pain  of  interstitial  in  contradistinc- 

tion to  that  of,  143 

—  placentation  in,  55 

—  process  of,  in  advanced  cases,  59 

—  question  of  removal  of  non-pregnant 

tube  as  routine  procedure  in  opera- 
tion for,  102 

— 'terminations  of,  in  advanced  cases, 
60 

considerations   affecting,  60 

by  death  of  embryo  with  the  for- 
mation of  tubal  mole,  35 

growth  and  development  of  fetus 

to  full  term,  while  still  confined 
within  the  tube,  41 

hematocele,  jy 

— ■  —  by  resorption  of  the  ovum,  34 

rupture,  57 

— ■ between  the  folds  of  the  broad 

ligament,  39 

followed  by  abortion,  57 

followed  by  tubal  mole,  58 

into  the  peritoneal  cavity,  37 

secondary,  intraligamentary  preg- 
nancy, 44 

—  secondary  abdominal  preg- 
nancy,   43 

tubo-abdominal  pregnancy,  42 

tubo-ovarian  pregnancy,  43 

by  tubal  abortion,  35 

—  tissue      changes      resulting      from, 

chorioepithelioma,  84 

—  triplet,   106 

—  twin,    104 

diagnosis  of,  105 

— '  —  unilateral,  characteristic  case  of, 

105 

Tubal  rupture,  amount  of  hemorrhage 
in,  as  compared  with  tubal  abor- 
tion, 39 

— 'between  the  folds  of  the  broad  liga- 
ment, 39 

—  causes  of,  coitus,  41 

plugging     of     large     intervillous 

veins,  59 
spontaneous,  40 


Tubal  rupture,  causes  of,  trauma,  40 
vaginal  examinations,  40 

—  extratubal,  58 

—  followed  by  intraligamentary  preg- 

nancy, 44 

—  followed    by    secondary    abdominal 

pregnancy,  42 

—  resulting  in  tubal  mole,  58 

— ■  followed    by    tubo-abdominal    preg- 
nancy, 42 

—  mechanism  of,  57,  58 
acute,  58 

described  by  Miki  Kiutsi,  58 

—  more  frequently  due  to  normal  than 

to  pathological  embryo,  88 

—  into  the  peritoneal  cavity,  37 

— ■  relative  frequency  of  tubal  abortion 
and,  37 

—  resulting  in  tubal  abortion,  57 

—  secondary,  38 

—  similarity  of  tubal  abortion  to,  36 
Tubes,  fallopian,  See  Fallopian  Tubes 
Tubo-abdominal    pregnancy,    following 

tubal  rupture,  42 
Tubo-ovarian  pregnancy,  43 
Tumors,    pressure    from,    resulting    in 

extra-uterine  pregnancy,  24 

—  of   the   tube,    causing   extra-uterine 

pregnancy,  2.y 

—  uterine,   fibroid,    complicating   tubal 

pregnancy,  109 
Twin  ectopic  pregnancy,  104 

—  diagnosis  of,  105 

—  unilateral,  characteristic  case  of,  105 


Urination,  increased  frequency  of,  in 
ectopic  pregnancy,  126 

Uterine  abortion,  differentiated  from 
ectopic  gestation,  148 

Uterine  adenomyoma,  ectopic  preg- 
nancy occurring  in  gland  spaces  of, 
112 

Uterine  bleeding,  due  to  extra-uterine 
pregnancy,  62 

Uterine  decidua,  negative  findings  not 
indicative  of  absence  of,  64 

Uterine  decidua,  primary  factor  in  for- 
mation of,  87 

—  relation  of  decidual  casts  and,  to  ex- 
tra-uterine pregnancy,  64 

Uterine  involution,  due  to  tubal  preg- 
nancy, 62,  63 


INDEX 


189 


Uterine  involution,  due  to  tubal  preg- 
nancy, regressive  and  reparative 
stages  of,  63 

Uterine  tumors,  complicating  tubal 
pregnancy,  109 

Uterus,  changes  produced  in,  by  extra- 
uterine pregnancy,  formation  of 
decidua  vera,  62 

increase  in  size,  62 

involution,  62,  63 


Uterus,  changes  produced  in,  by  extra- 
uterine pregnancy,  uterine  bleed- 
ing,  62 

—  enlargement    of,    in    ectopic    preg- 

nancy, 125,  132 

—  increased  anteflexion  of,  in  ectopic 

pregnancy,  126,  132 

—  normally   pregnant,   retroversion   of, 

differentiated    from    extra-uterine 
pregnancy,  153 


CD 


Date  Due 

- 

i 

i 

I 

rWl  2?  i 

3/  r 

m* 

-' 

iwau 

"•  JD** 

:fw 

f) 

Extra-uterine  pregnancy 


2002179148 


nFn  i  a  w,k 


